MDedge Pediatrics

Finding the current domestic and global situations too disheartening to write about, I have decided for the moment to take the long view in hopes of finding something to stimulate your imaginations. It appears that we have several vaccines effective against SARS-CoV-2 if not in your hands at the moment at least in someone’s freezer or at the very least somewhere near beginning of their journey in the production pipeline. It may be a year of more but thanks to the vaccines and herd immunity there will be a time when parents may feel more comfortable about bringing their children into your office. How are you going to dial back your office routine to something even vaguely familiar?

To keep your office afloat financially you have probably been forced to adopt and adapt telemedicine strategies to your practice style. Prior to the pandemic you may have been among the few who were actively experimenting with practicing remotely. But, it is more likely that you had given little serious thought to how you would manage your patients without them being physically present.

You probably carried in your mind a list of symptoms and complaints which you had promised yourself that you would never treat without first laying eyes and hands on the patient. You may have even codified this list into a set of guidelines that you included in the office manual for your nurses, assistants, and receptionists. You may have looked askance at some of your colleagues whom you felt too often treated their patients (and yours when they were covering) based on what seemed to be scanty information gleaned from a phone call. The impropriety of this kind of clinical behavior may have even come up at staff meetings or at least been the topic of hallway discussions.

How did your list of complaints that demanded an in-person visit evolve? I suspect that in large part it was formed as you modeled the behavior of your mentors and teachers. In some cases you may have heard of tragic cases in which a child had died or suffered serious consequences of being treated without an in-person evaluation. In many cases you were following a tradition or ethic that said treating in certain circumstances without an exam just wasn’t done.

Have the realities of the pandemic forced you to alter your list of must-see-before-I’ll-treat complaints? Have you found yourself calling in antibiotic prescriptions for children with ear pain who 1 year ago you would have told to come in for an office visit? Are you treating “strep throats” without a rapid strep test or culture? How many stimulant prescriptions have you refilled for children who haven’t been reevaluated in the office in over a year? How are you going to manage the tsunami of requests for sports physicals once the junior high and high school teams are allowed to return to action? You probably won’t have the time to examine all of the sports candidates who show up in your office with crumpled forms recently retrieved from crumb-filled backpacks.

Where are you going to reset the bar as the pandemic lifts and the barriers that have prevented patients from coming to your office over the last year or year and a half recede? Have you realized that many of your office visits in prepandemic times were unnecessary? How many children with otitis really needed to be followed up with an ear recheck visit? Which children with sore throats and a fever needed to be examined? Was a yearly exam really necessary for a high school sophomore who wanted to play basketball? Has your comfort zone widened to include more patient complaints that can be managed without a face to face encounter? Where will telemedicine fit into the mix?

At some time in the next 12 months you will have to recalibrate and reset the bar. It will probably be a gradual process that in large part can be molded by the responses of the families who may have also come to realize that seeing you in the office isn’t quite as necessary as you both may have thought it was.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]

Finding the current domestic and global situations too disheartening to write about, I have decided for the moment to take the long view in hopes of finding something to stimulate your imaginations. It appears that we have several vaccines effective against SARS-CoV-2 if not in your hands at the moment at least in someone’s freezer or at the very least somewhere near beginning of their journey in the production pipeline. It may be a year of more but thanks to the vaccines and herd immunity there will be a time when parents may feel more comfortable about bringing their children into your office. How are you going to dial back your office routine to something even vaguely familiar?

To keep your office afloat financially you have probably been forced to adopt and adapt telemedicine strategies to your practice style. Prior to the pandemic you may have been among the few who were actively experimenting with practicing remotely. But, it is more likely that you had given little serious thought to how you would manage your patients without them being physically present.

You probably carried in your mind a list of symptoms and complaints which you had promised yourself that you would never treat without first laying eyes and hands on the patient. You may have even codified this list into a set of guidelines that you included in the office manual for your nurses, assistants, and receptionists. You may have looked askance at some of your colleagues whom you felt too often treated their patients (and yours when they were covering) based on what seemed to be scanty information gleaned from a phone call. The impropriety of this kind of clinical behavior may have even come up at staff meetings or at least been the topic of hallway discussions.

How did your list of complaints that demanded an in-person visit evolve? I suspect that in large part it was formed as you modeled the behavior of your mentors and teachers. In some cases you may have heard of tragic cases in which a child had died or suffered serious consequences of being treated without an in-person evaluation. In many cases you were following a tradition or ethic that said treating in certain circumstances without an exam just wasn’t done.

Have the realities of the pandemic forced you to alter your list of must-see-before-I’ll-treat complaints? Have you found yourself calling in antibiotic prescriptions for children with ear pain who 1 year ago you would have told to come in for an office visit? Are you treating “strep throats” without a rapid strep test or culture? How many stimulant prescriptions have you refilled for children who haven’t been reevaluated in the office in over a year? How are you going to manage the tsunami of requests for sports physicals once the junior high and high school teams are allowed to return to action? You probably won’t have the time to examine all of the sports candidates who show up in your office with crumpled forms recently retrieved from crumb-filled backpacks.

Where are you going to reset the bar as the pandemic lifts and the barriers that have prevented patients from coming to your office over the last year or year and a half recede? Have you realized that many of your office visits in prepandemic times were unnecessary? How many children with otitis really needed to be followed up with an ear recheck visit? Which children with sore throats and a fever needed to be examined? Was a yearly exam really necessary for a high school sophomore who wanted to play basketball? Has your comfort zone widened to include more patient complaints that can be managed without a face to face encounter? Where will telemedicine fit into the mix?

At some time in the next 12 months you will have to recalibrate and reset the bar. It will probably be a gradual process that in large part can be molded by the responses of the families who may have also come to realize that seeing you in the office isn’t quite as necessary as you both may have thought it was.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]

Finding the current domestic and global situations too disheartening to write about, I have decided for the moment to take the long view in hopes of finding something to stimulate your imaginations. It appears that we have several vaccines effective against SARS-CoV-2 if not in your hands at the moment at least in someone’s freezer or at the very least somewhere near beginning of their journey in the production pipeline. It may be a year of more but thanks to the vaccines and herd immunity there will be a time when parents may feel more comfortable about bringing their children into your office. How are you going to dial back your office routine to something even vaguely familiar?

To keep your office afloat financially you have probably been forced to adopt and adapt telemedicine strategies to your practice style. Prior to the pandemic you may have been among the few who were actively experimenting with practicing remotely. But, it is more likely that you had given little serious thought to how you would manage your patients without them being physically present.

You probably carried in your mind a list of symptoms and complaints which you had promised yourself that you would never treat without first laying eyes and hands on the patient. You may have even codified this list into a set of guidelines that you included in the office manual for your nurses, assistants, and receptionists. You may have looked askance at some of your colleagues whom you felt too often treated their patients (and yours when they were covering) based on what seemed to be scanty information gleaned from a phone call. The impropriety of this kind of clinical behavior may have even come up at staff meetings or at least been the topic of hallway discussions.

How did your list of complaints that demanded an in-person visit evolve? I suspect that in large part it was formed as you modeled the behavior of your mentors and teachers. In some cases you may have heard of tragic cases in which a child had died or suffered serious consequences of being treated without an in-person evaluation. In many cases you were following a tradition or ethic that said treating in certain circumstances without an exam just wasn’t done.

Have the realities of the pandemic forced you to alter your list of must-see-before-I’ll-treat complaints? Have you found yourself calling in antibiotic prescriptions for children with ear pain who 1 year ago you would have told to come in for an office visit? Are you treating “strep throats” without a rapid strep test or culture? How many stimulant prescriptions have you refilled for children who haven’t been reevaluated in the office in over a year? How are you going to manage the tsunami of requests for sports physicals once the junior high and high school teams are allowed to return to action? You probably won’t have the time to examine all of the sports candidates who show up in your office with crumpled forms recently retrieved from crumb-filled backpacks.

Where are you going to reset the bar as the pandemic lifts and the barriers that have prevented patients from coming to your office over the last year or year and a half recede? Have you realized that many of your office visits in prepandemic times were unnecessary? How many children with otitis really needed to be followed up with an ear recheck visit? Which children with sore throats and a fever needed to be examined? Was a yearly exam really necessary for a high school sophomore who wanted to play basketball? Has your comfort zone widened to include more patient complaints that can be managed without a face to face encounter? Where will telemedicine fit into the mix?

At some time in the next 12 months you will have to recalibrate and reset the bar. It will probably be a gradual process that in large part can be molded by the responses of the families who may have also come to realize that seeing you in the office isn’t quite as necessary as you both may have thought it was.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]

Home-based preventive interventions not only improve healthy eating habits and self-regulation in toddlers but also guide their parents toward better food presentation and response to picky behaviors, reported Robert L. Nix, PhD, of the University of Wisconsin, Madison, and his associates.

In a small, randomized controlled trial of 73 families with toddlers aged 18-36 months enrolled in home-based Early Head Start (EHS), the researchers evaluated four protective factors, including toddlers’ healthy eating habits, toddlers’ self-regulation, parents’ responsive feeding practices, and parents’ sensitive scaffolding. The study, conducted from April to October 2013, is the first clinical trial of Recipe 4 Success, a preschool-focused intervention created by administrators and home visitors of EHS that promotes healthy eating and self-regulation in toddlers living in poverty who may otherwise face weight challenges and obesity later in life. Integrating the intervention into EHS allowed the researchers to take full advantage of its national infrastructure and to make dissemination more efficient.

Of the families selected to participate, all of whom were living below the Federal poverty threshold, 66 were retained through post treatment. Most participating parents were biological mothers; 61% were single; 29% were not high school graduates; just 11% were employed full time. The toddlers averaged 30.72 months; 44% were female. Roughly 48% of families were non-Hispanic White; 29% were Black; and 23% were Hispanic or Latinx, the investigators reported in Pediatrics. More than three-quarters of participants were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children or the Supplemental Nutrition Assistance Program.
 

The program allowed parents to transform toddler eating habits quickly

The study, which was designed to evaluate for posttreatment differences in the primary outcomes, involved 10 consecutive weekly lessons implemented by regularly assigned EHS home visitors. Parents were required to adhere to feeding practices carefully targeted with sensitive, structured scaffolding designed to keep toddlers from becoming overwhelmed. Parents were guided to understand, for instance, that toddlers frequently need to be exposed to a new food 10-20 times before eating it, and that poor sleep can have a detrimental influence on emotional and behavioral controls that can progress to weight gain.

Parent recall of what food and drinks their toddlers consumed in the previous 24-hour period was collected by interviewers. The percentage of all meals that included a fruit and/or vegetable, a protein source, and the absence of sweets and junk food were noted. Toddler self-regulation was assessed in accordance with delay of gratification, task orientation, and emotional/behavioral control. Parents were asked to rate toddler ability to cease desired activities to comply with parental requests. Parental responsive feeding practices were also recorded to observe how they introduce unique healthy foods and how they responded to their toddlers’ reactions. Parental sensitive scaffolding was similarly observed for their ability to structure activities in a developmentally appropriate manner promoting self-regulation.

The researchers noted no statistically significant differences between families in the treatment and control groups, nor were there differences in outcome measures or covariates. Study findings showed that, compared with toddlers who continued to receive just EHS support, the toddlers randomly assigned to Recipe 4 Success were more likely to consume snacks and meals that contained fruits, vegetables, protein, and no sweets or junk food.

As the results of this study and others have shown, early food preferences offer the strongest indication of later diet and healthy eating habits throughout life. The program targeted in this study is significant in its ability to accelerate the adoption of better toddler eating habits in just a 10-week period.

Recipe 4 Success along with other successful preventive interventions for young children are most effective when parents drive the change. “In the present trial, the quality of parenting was most highly related to healthy eating habits and self-regulation at baseline,” the researchers noted.

Specifically, the authors attributed the success of the program to “targeting specific interrelated outcomes with an integrated, theoretically driven intervention model,” which allowed Recipe 4 Success to boost the effectiveness of EHS substantially “in just 10 weeks with a minimal increase in funding,” the authors added.

The authors noted several weaknesses as well as strengths of the study. Its primary weakness was a baseline-posttreatment design, which made it impossible to assert that intervention effects can be sustained. The study was also limited to English-speaking families. Given that most home visitors attended to families in both Recipe 4 Success and EHS, the researchers noted the possibility for contamination across conditions, but they added that this would have actually reduced the intervention effects. The study’s primary strength was the evidenced-based nature of the randomized control. That Recipe 4 Success was operated as an intervention only strengthen the benefits of normal EHS visits.
 

Patient parents who promote self-regulation have the best chance of success

“This small study emphasizes the importance of parent education and support in setting the toddlers’ palate for lifelong eating habits and self-regulation,” observed Silver Spring, MD, private practice pediatrician and associate clinical professor of pediatrics at George Washington University, Washington, Lillian M. Beard, MD, in a separate interview.

“With the goal of promoting eating habits and self-regulation, I try to guide parents’ choices of what they offer to their toddler. I applaud parents’ patience as I encourage them not to give in and quickly resort to offering salty or sweet snacks. I suggest that if during the course of a day, a palette of colorful healthy choices is offered, most toddlers will graze independently as they go about their play. The challenge is to really support the parent through this quirky stage of their child’s development,” she explained.

“The ultimate challenge today with so much food insecurity, COVID-19 related job losses, and shrinking dollars to feed families is that too many families are feeling a food crisis! A program such as Recipe 4 Success can provide invaluable education for families on how to best stretch their few dollars, with knowledge of which items to seek from their community food pantries, how to best utilize items from the State WIC programs and still seek nutrition tips from their pediatricians while avoiding expensive fast foods that only offer immediate satiety and gratification. The Recipe 4 Success educator, pediatrician, or any community educator can give recommendations about which fresh produce may be inexpensive, but nutritional,” Dr. Beard suggested.

Dr. Nix and colleagues as well as Dr. Beard had no conflicts of interest and no relevant financial disclosures.
 

Home-based preventive interventions not only improve healthy eating habits and self-regulation in toddlers but also guide their parents toward better food presentation and response to picky behaviors, reported Robert L. Nix, PhD, of the University of Wisconsin, Madison, and his associates.

In a small, randomized controlled trial of 73 families with toddlers aged 18-36 months enrolled in home-based Early Head Start (EHS), the researchers evaluated four protective factors, including toddlers’ healthy eating habits, toddlers’ self-regulation, parents’ responsive feeding practices, and parents’ sensitive scaffolding. The study, conducted from April to October 2013, is the first clinical trial of Recipe 4 Success, a preschool-focused intervention created by administrators and home visitors of EHS that promotes healthy eating and self-regulation in toddlers living in poverty who may otherwise face weight challenges and obesity later in life. Integrating the intervention into EHS allowed the researchers to take full advantage of its national infrastructure and to make dissemination more efficient.

Of the families selected to participate, all of whom were living below the Federal poverty threshold, 66 were retained through post treatment. Most participating parents were biological mothers; 61% were single; 29% were not high school graduates; just 11% were employed full time. The toddlers averaged 30.72 months; 44% were female. Roughly 48% of families were non-Hispanic White; 29% were Black; and 23% were Hispanic or Latinx, the investigators reported in Pediatrics. More than three-quarters of participants were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children or the Supplemental Nutrition Assistance Program.
 

The program allowed parents to transform toddler eating habits quickly

The study, which was designed to evaluate for posttreatment differences in the primary outcomes, involved 10 consecutive weekly lessons implemented by regularly assigned EHS home visitors. Parents were required to adhere to feeding practices carefully targeted with sensitive, structured scaffolding designed to keep toddlers from becoming overwhelmed. Parents were guided to understand, for instance, that toddlers frequently need to be exposed to a new food 10-20 times before eating it, and that poor sleep can have a detrimental influence on emotional and behavioral controls that can progress to weight gain.

Parent recall of what food and drinks their toddlers consumed in the previous 24-hour period was collected by interviewers. The percentage of all meals that included a fruit and/or vegetable, a protein source, and the absence of sweets and junk food were noted. Toddler self-regulation was assessed in accordance with delay of gratification, task orientation, and emotional/behavioral control. Parents were asked to rate toddler ability to cease desired activities to comply with parental requests. Parental responsive feeding practices were also recorded to observe how they introduce unique healthy foods and how they responded to their toddlers’ reactions. Parental sensitive scaffolding was similarly observed for their ability to structure activities in a developmentally appropriate manner promoting self-regulation.

The researchers noted no statistically significant differences between families in the treatment and control groups, nor were there differences in outcome measures or covariates. Study findings showed that, compared with toddlers who continued to receive just EHS support, the toddlers randomly assigned to Recipe 4 Success were more likely to consume snacks and meals that contained fruits, vegetables, protein, and no sweets or junk food.

As the results of this study and others have shown, early food preferences offer the strongest indication of later diet and healthy eating habits throughout life. The program targeted in this study is significant in its ability to accelerate the adoption of better toddler eating habits in just a 10-week period.

Recipe 4 Success along with other successful preventive interventions for young children are most effective when parents drive the change. “In the present trial, the quality of parenting was most highly related to healthy eating habits and self-regulation at baseline,” the researchers noted.

Specifically, the authors attributed the success of the program to “targeting specific interrelated outcomes with an integrated, theoretically driven intervention model,” which allowed Recipe 4 Success to boost the effectiveness of EHS substantially “in just 10 weeks with a minimal increase in funding,” the authors added.

The authors noted several weaknesses as well as strengths of the study. Its primary weakness was a baseline-posttreatment design, which made it impossible to assert that intervention effects can be sustained. The study was also limited to English-speaking families. Given that most home visitors attended to families in both Recipe 4 Success and EHS, the researchers noted the possibility for contamination across conditions, but they added that this would have actually reduced the intervention effects. The study’s primary strength was the evidenced-based nature of the randomized control. That Recipe 4 Success was operated as an intervention only strengthen the benefits of normal EHS visits.
 

Patient parents who promote self-regulation have the best chance of success

“This small study emphasizes the importance of parent education and support in setting the toddlers’ palate for lifelong eating habits and self-regulation,” observed Silver Spring, MD, private practice pediatrician and associate clinical professor of pediatrics at George Washington University, Washington, Lillian M. Beard, MD, in a separate interview.

“With the goal of promoting eating habits and self-regulation, I try to guide parents’ choices of what they offer to their toddler. I applaud parents’ patience as I encourage them not to give in and quickly resort to offering salty or sweet snacks. I suggest that if during the course of a day, a palette of colorful healthy choices is offered, most toddlers will graze independently as they go about their play. The challenge is to really support the parent through this quirky stage of their child’s development,” she explained.

“The ultimate challenge today with so much food insecurity, COVID-19 related job losses, and shrinking dollars to feed families is that too many families are feeling a food crisis! A program such as Recipe 4 Success can provide invaluable education for families on how to best stretch their few dollars, with knowledge of which items to seek from their community food pantries, how to best utilize items from the State WIC programs and still seek nutrition tips from their pediatricians while avoiding expensive fast foods that only offer immediate satiety and gratification. The Recipe 4 Success educator, pediatrician, or any community educator can give recommendations about which fresh produce may be inexpensive, but nutritional,” Dr. Beard suggested.

Dr. Nix and colleagues as well as Dr. Beard had no conflicts of interest and no relevant financial disclosures.
 

Home-based preventive interventions not only improve healthy eating habits and self-regulation in toddlers but also guide their parents toward better food presentation and response to picky behaviors, reported Robert L. Nix, PhD, of the University of Wisconsin, Madison, and his associates.

In a small, randomized controlled trial of 73 families with toddlers aged 18-36 months enrolled in home-based Early Head Start (EHS), the researchers evaluated four protective factors, including toddlers’ healthy eating habits, toddlers’ self-regulation, parents’ responsive feeding practices, and parents’ sensitive scaffolding. The study, conducted from April to October 2013, is the first clinical trial of Recipe 4 Success, a preschool-focused intervention created by administrators and home visitors of EHS that promotes healthy eating and self-regulation in toddlers living in poverty who may otherwise face weight challenges and obesity later in life. Integrating the intervention into EHS allowed the researchers to take full advantage of its national infrastructure and to make dissemination more efficient.

Of the families selected to participate, all of whom were living below the Federal poverty threshold, 66 were retained through post treatment. Most participating parents were biological mothers; 61% were single; 29% were not high school graduates; just 11% were employed full time. The toddlers averaged 30.72 months; 44% were female. Roughly 48% of families were non-Hispanic White; 29% were Black; and 23% were Hispanic or Latinx, the investigators reported in Pediatrics. More than three-quarters of participants were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children or the Supplemental Nutrition Assistance Program.
 

The program allowed parents to transform toddler eating habits quickly

The study, which was designed to evaluate for posttreatment differences in the primary outcomes, involved 10 consecutive weekly lessons implemented by regularly assigned EHS home visitors. Parents were required to adhere to feeding practices carefully targeted with sensitive, structured scaffolding designed to keep toddlers from becoming overwhelmed. Parents were guided to understand, for instance, that toddlers frequently need to be exposed to a new food 10-20 times before eating it, and that poor sleep can have a detrimental influence on emotional and behavioral controls that can progress to weight gain.

Parent recall of what food and drinks their toddlers consumed in the previous 24-hour period was collected by interviewers. The percentage of all meals that included a fruit and/or vegetable, a protein source, and the absence of sweets and junk food were noted. Toddler self-regulation was assessed in accordance with delay of gratification, task orientation, and emotional/behavioral control. Parents were asked to rate toddler ability to cease desired activities to comply with parental requests. Parental responsive feeding practices were also recorded to observe how they introduce unique healthy foods and how they responded to their toddlers’ reactions. Parental sensitive scaffolding was similarly observed for their ability to structure activities in a developmentally appropriate manner promoting self-regulation.

The researchers noted no statistically significant differences between families in the treatment and control groups, nor were there differences in outcome measures or covariates. Study findings showed that, compared with toddlers who continued to receive just EHS support, the toddlers randomly assigned to Recipe 4 Success were more likely to consume snacks and meals that contained fruits, vegetables, protein, and no sweets or junk food.

As the results of this study and others have shown, early food preferences offer the strongest indication of later diet and healthy eating habits throughout life. The program targeted in this study is significant in its ability to accelerate the adoption of better toddler eating habits in just a 10-week period.

Recipe 4 Success along with other successful preventive interventions for young children are most effective when parents drive the change. “In the present trial, the quality of parenting was most highly related to healthy eating habits and self-regulation at baseline,” the researchers noted.

Specifically, the authors attributed the success of the program to “targeting specific interrelated outcomes with an integrated, theoretically driven intervention model,” which allowed Recipe 4 Success to boost the effectiveness of EHS substantially “in just 10 weeks with a minimal increase in funding,” the authors added.

The authors noted several weaknesses as well as strengths of the study. Its primary weakness was a baseline-posttreatment design, which made it impossible to assert that intervention effects can be sustained. The study was also limited to English-speaking families. Given that most home visitors attended to families in both Recipe 4 Success and EHS, the researchers noted the possibility for contamination across conditions, but they added that this would have actually reduced the intervention effects. The study’s primary strength was the evidenced-based nature of the randomized control. That Recipe 4 Success was operated as an intervention only strengthen the benefits of normal EHS visits.
 

Patient parents who promote self-regulation have the best chance of success

“This small study emphasizes the importance of parent education and support in setting the toddlers’ palate for lifelong eating habits and self-regulation,” observed Silver Spring, MD, private practice pediatrician and associate clinical professor of pediatrics at George Washington University, Washington, Lillian M. Beard, MD, in a separate interview.

“With the goal of promoting eating habits and self-regulation, I try to guide parents’ choices of what they offer to their toddler. I applaud parents’ patience as I encourage them not to give in and quickly resort to offering salty or sweet snacks. I suggest that if during the course of a day, a palette of colorful healthy choices is offered, most toddlers will graze independently as they go about their play. The challenge is to really support the parent through this quirky stage of their child’s development,” she explained.

“The ultimate challenge today with so much food insecurity, COVID-19 related job losses, and shrinking dollars to feed families is that too many families are feeling a food crisis! A program such as Recipe 4 Success can provide invaluable education for families on how to best stretch their few dollars, with knowledge of which items to seek from their community food pantries, how to best utilize items from the State WIC programs and still seek nutrition tips from their pediatricians while avoiding expensive fast foods that only offer immediate satiety and gratification. The Recipe 4 Success educator, pediatrician, or any community educator can give recommendations about which fresh produce may be inexpensive, but nutritional,” Dr. Beard suggested.

Dr. Nix and colleagues as well as Dr. Beard had no conflicts of interest and no relevant financial disclosures.
 

Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during acute COVID-19 illness raises the risk for euglycemic diabetic ketoacidosis (euDKA), a new case series suggests.

Five patients with type 2 diabetes who were taking SGLT2 inhibitors presented in DKA despite having glucose levels below 300 mg/dL. The report was published online last month in AACE Clinical Case Reports by Rebecca J. Vitale, MD, and colleagues at Brigham and Women’s Hospital, Boston.

“A cluster of euglycemic DKA cases at our hospital during the first wave of the pandemic suggests that patients with diabetes taking SGLT2 inhibitors may be at enhanced risk for euDKA when they contract COVID-19,” senior author Naomi D.L. Fisher, MD, said in an interview.

Dr. Fisher, an endocrinologist, added: “This complication is preventable with the simple measure of holding the drug. We are hopeful that widespread patient and physician education will prevent future cases of euDKA as COVID-19 infections continue to surge.”

These cases underscore recommendations published early in the COVID-19 pandemic by an international panel, she noted.

“Patients who are acutely ill with nausea, vomiting, abdominal pain, or diarrhea, or who are experiencing loss of appetite with reduced food and fluid intake, should be advised to hold their SGLT2 inhibitor. This medication should not be resumed until patients are feeling better and eating and drinking normally.”  

On the other hand, “If patients with asymptomatic or mild COVID-19 infection are otherwise well, and are eating and drinking normally, there is no evidence that SGLT2 inhibitors need to be stopped. These patients should monitor [themselves] closely for worsening symptoms, especially resulting in poor hydration and nutrition, which would be reason to discontinue their medication.” 
 

Pay special attention to the elderly, those with complications

However, special consideration should be given to elderly patients and those with medical conditions known to increase the likelihood of severe infection, like heart failure and chronic obstructive pulmonary disease, Dr. Fisher added.

The SGLT2 inhibitor class of drugs causes significant urinary glucose excretion, and they are also diuretics. A decrease in available glucose and volume depletion are probably both important contributors to euDKA, she explained.

With COVID-19 infection the euDKA risk is compounded by several mechanisms. Most cases of euDKA are associated with an underlying state of starvation that can be triggered by vomiting, diarrhea, loss of appetite, and poor oral intake.

In addition – although not yet known for certain – SARS-CoV-2 may also be toxic to pancreatic beta cells and thus reduce insulin secretion. The maladaptive inflammatory response seen with COVID-19 may also contribute, she said.  

The patients in the current case series were three men and two women seen between March and May 2020. They ranged in age from 52 to 79 years.

None had a prior history of DKA or any known diabetes complications. In all of them, antihyperglycemic medications, including SGLT2 inhibitors, were stopped on hospital admission. The patients were initially treated with intravenous insulin, and then subcutaneous insulin after the DKA diagnosis.

Three of the patients were discharged to rehabilitation facilities on hospital days 28-47 and one (age 53 years) was discharged home on day 11. The other patient also had hypertension and nonalcoholic steatohepatitis.

A version of this article first appeared on Medscape.com.

Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during acute COVID-19 illness raises the risk for euglycemic diabetic ketoacidosis (euDKA), a new case series suggests.

Five patients with type 2 diabetes who were taking SGLT2 inhibitors presented in DKA despite having glucose levels below 300 mg/dL. The report was published online last month in AACE Clinical Case Reports by Rebecca J. Vitale, MD, and colleagues at Brigham and Women’s Hospital, Boston.

“A cluster of euglycemic DKA cases at our hospital during the first wave of the pandemic suggests that patients with diabetes taking SGLT2 inhibitors may be at enhanced risk for euDKA when they contract COVID-19,” senior author Naomi D.L. Fisher, MD, said in an interview.

Dr. Fisher, an endocrinologist, added: “This complication is preventable with the simple measure of holding the drug. We are hopeful that widespread patient and physician education will prevent future cases of euDKA as COVID-19 infections continue to surge.”

These cases underscore recommendations published early in the COVID-19 pandemic by an international panel, she noted.

“Patients who are acutely ill with nausea, vomiting, abdominal pain, or diarrhea, or who are experiencing loss of appetite with reduced food and fluid intake, should be advised to hold their SGLT2 inhibitor. This medication should not be resumed until patients are feeling better and eating and drinking normally.”  

On the other hand, “If patients with asymptomatic or mild COVID-19 infection are otherwise well, and are eating and drinking normally, there is no evidence that SGLT2 inhibitors need to be stopped. These patients should monitor [themselves] closely for worsening symptoms, especially resulting in poor hydration and nutrition, which would be reason to discontinue their medication.” 
 

Pay special attention to the elderly, those with complications

However, special consideration should be given to elderly patients and those with medical conditions known to increase the likelihood of severe infection, like heart failure and chronic obstructive pulmonary disease, Dr. Fisher added.

The SGLT2 inhibitor class of drugs causes significant urinary glucose excretion, and they are also diuretics. A decrease in available glucose and volume depletion are probably both important contributors to euDKA, she explained.

With COVID-19 infection the euDKA risk is compounded by several mechanisms. Most cases of euDKA are associated with an underlying state of starvation that can be triggered by vomiting, diarrhea, loss of appetite, and poor oral intake.

In addition – although not yet known for certain – SARS-CoV-2 may also be toxic to pancreatic beta cells and thus reduce insulin secretion. The maladaptive inflammatory response seen with COVID-19 may also contribute, she said.  

The patients in the current case series were three men and two women seen between March and May 2020. They ranged in age from 52 to 79 years.

None had a prior history of DKA or any known diabetes complications. In all of them, antihyperglycemic medications, including SGLT2 inhibitors, were stopped on hospital admission. The patients were initially treated with intravenous insulin, and then subcutaneous insulin after the DKA diagnosis.

Three of the patients were discharged to rehabilitation facilities on hospital days 28-47 and one (age 53 years) was discharged home on day 11. The other patient also had hypertension and nonalcoholic steatohepatitis.

A version of this article first appeared on Medscape.com.

Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during acute COVID-19 illness raises the risk for euglycemic diabetic ketoacidosis (euDKA), a new case series suggests.

Five patients with type 2 diabetes who were taking SGLT2 inhibitors presented in DKA despite having glucose levels below 300 mg/dL. The report was published online last month in AACE Clinical Case Reports by Rebecca J. Vitale, MD, and colleagues at Brigham and Women’s Hospital, Boston.

“A cluster of euglycemic DKA cases at our hospital during the first wave of the pandemic suggests that patients with diabetes taking SGLT2 inhibitors may be at enhanced risk for euDKA when they contract COVID-19,” senior author Naomi D.L. Fisher, MD, said in an interview.

Dr. Fisher, an endocrinologist, added: “This complication is preventable with the simple measure of holding the drug. We are hopeful that widespread patient and physician education will prevent future cases of euDKA as COVID-19 infections continue to surge.”

These cases underscore recommendations published early in the COVID-19 pandemic by an international panel, she noted.

“Patients who are acutely ill with nausea, vomiting, abdominal pain, or diarrhea, or who are experiencing loss of appetite with reduced food and fluid intake, should be advised to hold their SGLT2 inhibitor. This medication should not be resumed until patients are feeling better and eating and drinking normally.”  

On the other hand, “If patients with asymptomatic or mild COVID-19 infection are otherwise well, and are eating and drinking normally, there is no evidence that SGLT2 inhibitors need to be stopped. These patients should monitor [themselves] closely for worsening symptoms, especially resulting in poor hydration and nutrition, which would be reason to discontinue their medication.” 
 

Pay special attention to the elderly, those with complications

However, special consideration should be given to elderly patients and those with medical conditions known to increase the likelihood of severe infection, like heart failure and chronic obstructive pulmonary disease, Dr. Fisher added.

The SGLT2 inhibitor class of drugs causes significant urinary glucose excretion, and they are also diuretics. A decrease in available glucose and volume depletion are probably both important contributors to euDKA, she explained.

With COVID-19 infection the euDKA risk is compounded by several mechanisms. Most cases of euDKA are associated with an underlying state of starvation that can be triggered by vomiting, diarrhea, loss of appetite, and poor oral intake.

In addition – although not yet known for certain – SARS-CoV-2 may also be toxic to pancreatic beta cells and thus reduce insulin secretion. The maladaptive inflammatory response seen with COVID-19 may also contribute, she said.  

The patients in the current case series were three men and two women seen between March and May 2020. They ranged in age from 52 to 79 years.

None had a prior history of DKA or any known diabetes complications. In all of them, antihyperglycemic medications, including SGLT2 inhibitors, were stopped on hospital admission. The patients were initially treated with intravenous insulin, and then subcutaneous insulin after the DKA diagnosis.

Three of the patients were discharged to rehabilitation facilities on hospital days 28-47 and one (age 53 years) was discharged home on day 11. The other patient also had hypertension and nonalcoholic steatohepatitis.

A version of this article first appeared on Medscape.com.

The United States set a new weekly high for COVID-19 cases in children, surpassing 200,000 for the first time since the pandemic began, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

There were 211,466 new cases reported in children during the week of Jan. 8-14, topping the previous high (Dec. 11-17) by almost 30,000. Those new cases bring the total for the pandemic to over 2.5 million children infected with the coronavirus, which represents 12.6% of all reported cases, the AAP and the CHA said Jan. 19 in their weekly COVID-19 report.

The rise in cases also brought an increase in the proportion reported among children. The week before (Jan. 1-7), cases in children were 12.9% of all cases reported, but the most recent week saw that number rise to 14.5% of all cases, the highest it’s been since early October, based on data collected from the health department websites of 49 states (excluding New York), the District of Columbia, New York City, Puerto Rio, and Guam.

The corresponding figures for severe illness continue to be low: Children represent 1.8% of all hospitalizations from COVID-19 in 24 states and New York City and 0.06% of all deaths in 43 states and New York City. Three deaths were reported for the week of Jan. 8-14, making for a total of 191 since the pandemic started, the AAP and CHA said in their report.

Among the states, California has the most overall cases at just over 350,000, Wyoming has the highest proportion of cases in children (20.3%), and North Dakota has the highest rate of infection (over 8,100 per 100,000 children). The infection rate for the nation is now above 3,300 per 100,000 children, and 11 states reported rates over 5,000, according to the AAP and the CHA.

[email protected]

The United States set a new weekly high for COVID-19 cases in children, surpassing 200,000 for the first time since the pandemic began, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

There were 211,466 new cases reported in children during the week of Jan. 8-14, topping the previous high (Dec. 11-17) by almost 30,000. Those new cases bring the total for the pandemic to over 2.5 million children infected with the coronavirus, which represents 12.6% of all reported cases, the AAP and the CHA said Jan. 19 in their weekly COVID-19 report.

The rise in cases also brought an increase in the proportion reported among children. The week before (Jan. 1-7), cases in children were 12.9% of all cases reported, but the most recent week saw that number rise to 14.5% of all cases, the highest it’s been since early October, based on data collected from the health department websites of 49 states (excluding New York), the District of Columbia, New York City, Puerto Rio, and Guam.

The corresponding figures for severe illness continue to be low: Children represent 1.8% of all hospitalizations from COVID-19 in 24 states and New York City and 0.06% of all deaths in 43 states and New York City. Three deaths were reported for the week of Jan. 8-14, making for a total of 191 since the pandemic started, the AAP and CHA said in their report.

Among the states, California has the most overall cases at just over 350,000, Wyoming has the highest proportion of cases in children (20.3%), and North Dakota has the highest rate of infection (over 8,100 per 100,000 children). The infection rate for the nation is now above 3,300 per 100,000 children, and 11 states reported rates over 5,000, according to the AAP and the CHA.

[email protected]

The United States set a new weekly high for COVID-19 cases in children, surpassing 200,000 for the first time since the pandemic began, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

There were 211,466 new cases reported in children during the week of Jan. 8-14, topping the previous high (Dec. 11-17) by almost 30,000. Those new cases bring the total for the pandemic to over 2.5 million children infected with the coronavirus, which represents 12.6% of all reported cases, the AAP and the CHA said Jan. 19 in their weekly COVID-19 report.

The rise in cases also brought an increase in the proportion reported among children. The week before (Jan. 1-7), cases in children were 12.9% of all cases reported, but the most recent week saw that number rise to 14.5% of all cases, the highest it’s been since early October, based on data collected from the health department websites of 49 states (excluding New York), the District of Columbia, New York City, Puerto Rio, and Guam.

The corresponding figures for severe illness continue to be low: Children represent 1.8% of all hospitalizations from COVID-19 in 24 states and New York City and 0.06% of all deaths in 43 states and New York City. Three deaths were reported for the week of Jan. 8-14, making for a total of 191 since the pandemic started, the AAP and CHA said in their report.

Among the states, California has the most overall cases at just over 350,000, Wyoming has the highest proportion of cases in children (20.3%), and North Dakota has the highest rate of infection (over 8,100 per 100,000 children). The infection rate for the nation is now above 3,300 per 100,000 children, and 11 states reported rates over 5,000, according to the AAP and the CHA.

[email protected]

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.

The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.

Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.^1-5

By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.

His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.

When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.

His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.

The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.

What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.

Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.

While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”

According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.

While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.

Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.

As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.

While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
 

Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

References

1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.

2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.

3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).

4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.

5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.

*Updated 1/25/2021

The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.

The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.

Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.^1-5

By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.

His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.

When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.

His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.

The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.

What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.

Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.

While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”

According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.

While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.

Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.

As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.

While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
 

Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

References

1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.

2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.

3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).

4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.

5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.

*Updated 1/25/2021

The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.

The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.

Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.^1-5

By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.

His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.

When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.

His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.

The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.

What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.

Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.

While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”

According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.

While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.

Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.

As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.

While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
 

Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

References

1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.

2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.

3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).

4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.

5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.

*Updated 1/25/2021

Childhood treatment with recombinant human growth hormone was associated with a significantly increased risk of cardiovascular events, based on data from more than 3,000 individuals.

“Both excess levels of growth hormone and [growth hormone deficiency] have been associated with increased cardiovascular morbidity and mortality,” but data on long-term cardiovascular morbidity in individuals treated with growth hormone in childhood are lacking, wrote Anders Tinblad, MD, of Karolinska Institutet, Stockholm, and colleagues.

In a population-based cohort study published in JAMA Pediatrics, the researchers identified 3,408 Swedish patients treated as children with recombinant human growth hormone (rhGH) between Jan. 1, 1985, and Dec. 31, 2010, and compared each with 15 matched controls (a total of 50,036 controls). The patients were treated for one of three conditions: isolated growth hormone deficiency (GHD), small for gestational age (SGA), and idiopathic short stature (ISS).

Data on cardiovascular outcomes were collected from health care and population-based registers and analyzed between Jan. 1, 1985, and Dec. 31, 2014. The average age of the participants at the study’s end was 25.1 years.

In all, 1,809 cardiovascular disease events were recorded over a median follow-up period of 14.9 years, for an incidence rate of 25.6 events per 10,000 person-years in patients and 22.6 events per 10,000 person-years in controls.

When separated by sex, the incidence was higher in female patients compared with controls (31.2 vs. 23.4 events per 10,000 person-years, respectively, but similar in male patients vs. controls (23.3 vs. 22.3 events per 10,000 person-years). “Differences in estrogen levels or responsiveness to rhGH treatment have previously been hypothesized as possible explanations, but the underlying mechanism for this sex difference still remains unclear and merits further investigation,” the researchers wrote.

Overall, the highest adjusted hazard ratios occurred in subgroups of patients with the longest treatment duration (HR 2.08) and highest cumulative dose of growth hormone (HR 2.05), but no association was noted between highest daily hormone dose and cardiovascular event risk. Hazard ratios were higher across all three treatment subgroups of SGA, GHD, and ISS compared with controls (HR 1.97, 1.66, and 1.55, respectively).

“The association between childhood rhGH treatment and CVD events was also seen when assessing only severe CVD outcomes, but with even lower absolute risks,” the researchers noted.

The study findings were limited by several factors including the potential for confounding by treatment indication and the lack of long-term follow-up data given the relatively young age of the study population, the researchers said. The results were strengthened by the large sample size and showed that the absolute risk for overall and severe cardiovascular disease in children treated with growth hormones was low, “which could be reassuring to individual patients,” they added. However, “At the group level, and perhaps especially for female patients and those treated for SGA indication, further close monitoring and future studies of CVD safety are warranted,” they concluded.
 

Safety and ethical concerns persist

Although the study authors cite limited conclusions on causality and low absolute risk, several issues persist that prompt ongoing analysis of pediatric growth hormone use, namely “worrisome indirect evidence, challenges and limitations in the direct evidence, and the changing world of growth hormone treatment,” Adda Grimberg, MD, of the University of Pennsylvania, Philadelphia, wrote in an accompanying editorial.

“Although evidence asserts that neither growth hormone nor insulinlike growth factor I is carcinogenic, the basic science and oncology literatures are rife with reports showing that they can make aberrant cells more aggressive,” and such indirect evidence supports the need for more direct evidence of possible harm from growth hormone treatment, Dr. Grimberg wrote. Most current safety data on growth hormone come from postmarketing surveillance studies, but these studies do not include controls or data on outcomes after discontinuation of treatment, she noted.

The current study, while able to follow patients across the lifespan, cannot indicate “whether the small but increased risk of cardiovascular disease found in this study was caused by the pediatric growth hormone treatment that identified the participants, by the conditions being treated, by other potential confounder(s) not captured by the study’s methods, or by a combination of the above,” said Dr. Grimberg.

In addition, “the move from replacement of GHD to pharmacologic height augmentation in children who already make sufficient growth hormone had the potential to change the safety profile of treatment,” she said.

“Parents of patients in pediatric primary care practices and of patients seeking growth-related care in a subspecialty endocrine clinic rated treatment characteristics (i.e., proven efficacy and safety) as the factor most having a big or extreme effect on their growth-related medical decision-making,” Dr. Grimberg said. “The centrality of treatment safety to patient-family decision-making underscores the importance of continued scrutiny of growth hormone safety as the treatment and its recipients continue to evolve,” she concluded.

The study was supported by the Swedish Research Council, the Stockholm City Council, the Karolinska Institute, the Society for Child Care, Sahlgrenska University Hospital, and the Stockholm County Council’s combined clinical residency and PhD training program. Lead author Dr. Tidblad disclosed funding from the Society for Child Care and Stockholm County Council during the conduct of the study and personal fees from Pfizer. Dr. Grimberg disclosed serving as a member of the steering committee for the Pfizer International Growth Study Database, and as a consultant for the Pediatric Endocrine Society GH Deficiency Knowledge Center, sponsored by Sandoz AG.

Childhood treatment with recombinant human growth hormone was associated with a significantly increased risk of cardiovascular events, based on data from more than 3,000 individuals.

“Both excess levels of growth hormone and [growth hormone deficiency] have been associated with increased cardiovascular morbidity and mortality,” but data on long-term cardiovascular morbidity in individuals treated with growth hormone in childhood are lacking, wrote Anders Tinblad, MD, of Karolinska Institutet, Stockholm, and colleagues.

In a population-based cohort study published in JAMA Pediatrics, the researchers identified 3,408 Swedish patients treated as children with recombinant human growth hormone (rhGH) between Jan. 1, 1985, and Dec. 31, 2010, and compared each with 15 matched controls (a total of 50,036 controls). The patients were treated for one of three conditions: isolated growth hormone deficiency (GHD), small for gestational age (SGA), and idiopathic short stature (ISS).

Data on cardiovascular outcomes were collected from health care and population-based registers and analyzed between Jan. 1, 1985, and Dec. 31, 2014. The average age of the participants at the study’s end was 25.1 years.

In all, 1,809 cardiovascular disease events were recorded over a median follow-up period of 14.9 years, for an incidence rate of 25.6 events per 10,000 person-years in patients and 22.6 events per 10,000 person-years in controls.

When separated by sex, the incidence was higher in female patients compared with controls (31.2 vs. 23.4 events per 10,000 person-years, respectively, but similar in male patients vs. controls (23.3 vs. 22.3 events per 10,000 person-years). “Differences in estrogen levels or responsiveness to rhGH treatment have previously been hypothesized as possible explanations, but the underlying mechanism for this sex difference still remains unclear and merits further investigation,” the researchers wrote.

Overall, the highest adjusted hazard ratios occurred in subgroups of patients with the longest treatment duration (HR 2.08) and highest cumulative dose of growth hormone (HR 2.05), but no association was noted between highest daily hormone dose and cardiovascular event risk. Hazard ratios were higher across all three treatment subgroups of SGA, GHD, and ISS compared with controls (HR 1.97, 1.66, and 1.55, respectively).

“The association between childhood rhGH treatment and CVD events was also seen when assessing only severe CVD outcomes, but with even lower absolute risks,” the researchers noted.

The study findings were limited by several factors including the potential for confounding by treatment indication and the lack of long-term follow-up data given the relatively young age of the study population, the researchers said. The results were strengthened by the large sample size and showed that the absolute risk for overall and severe cardiovascular disease in children treated with growth hormones was low, “which could be reassuring to individual patients,” they added. However, “At the group level, and perhaps especially for female patients and those treated for SGA indication, further close monitoring and future studies of CVD safety are warranted,” they concluded.
 

Safety and ethical concerns persist

Although the study authors cite limited conclusions on causality and low absolute risk, several issues persist that prompt ongoing analysis of pediatric growth hormone use, namely “worrisome indirect evidence, challenges and limitations in the direct evidence, and the changing world of growth hormone treatment,” Adda Grimberg, MD, of the University of Pennsylvania, Philadelphia, wrote in an accompanying editorial.

“Although evidence asserts that neither growth hormone nor insulinlike growth factor I is carcinogenic, the basic science and oncology literatures are rife with reports showing that they can make aberrant cells more aggressive,” and such indirect evidence supports the need for more direct evidence of possible harm from growth hormone treatment, Dr. Grimberg wrote. Most current safety data on growth hormone come from postmarketing surveillance studies, but these studies do not include controls or data on outcomes after discontinuation of treatment, she noted.

The current study, while able to follow patients across the lifespan, cannot indicate “whether the small but increased risk of cardiovascular disease found in this study was caused by the pediatric growth hormone treatment that identified the participants, by the conditions being treated, by other potential confounder(s) not captured by the study’s methods, or by a combination of the above,” said Dr. Grimberg.

In addition, “the move from replacement of GHD to pharmacologic height augmentation in children who already make sufficient growth hormone had the potential to change the safety profile of treatment,” she said.

“Parents of patients in pediatric primary care practices and of patients seeking growth-related care in a subspecialty endocrine clinic rated treatment characteristics (i.e., proven efficacy and safety) as the factor most having a big or extreme effect on their growth-related medical decision-making,” Dr. Grimberg said. “The centrality of treatment safety to patient-family decision-making underscores the importance of continued scrutiny of growth hormone safety as the treatment and its recipients continue to evolve,” she concluded.

The study was supported by the Swedish Research Council, the Stockholm City Council, the Karolinska Institute, the Society for Child Care, Sahlgrenska University Hospital, and the Stockholm County Council’s combined clinical residency and PhD training program. Lead author Dr. Tidblad disclosed funding from the Society for Child Care and Stockholm County Council during the conduct of the study and personal fees from Pfizer. Dr. Grimberg disclosed serving as a member of the steering committee for the Pfizer International Growth Study Database, and as a consultant for the Pediatric Endocrine Society GH Deficiency Knowledge Center, sponsored by Sandoz AG.

Childhood treatment with recombinant human growth hormone was associated with a significantly increased risk of cardiovascular events, based on data from more than 3,000 individuals.

“Both excess levels of growth hormone and [growth hormone deficiency] have been associated with increased cardiovascular morbidity and mortality,” but data on long-term cardiovascular morbidity in individuals treated with growth hormone in childhood are lacking, wrote Anders Tinblad, MD, of Karolinska Institutet, Stockholm, and colleagues.

In a population-based cohort study published in JAMA Pediatrics, the researchers identified 3,408 Swedish patients treated as children with recombinant human growth hormone (rhGH) between Jan. 1, 1985, and Dec. 31, 2010, and compared each with 15 matched controls (a total of 50,036 controls). The patients were treated for one of three conditions: isolated growth hormone deficiency (GHD), small for gestational age (SGA), and idiopathic short stature (ISS).

Data on cardiovascular outcomes were collected from health care and population-based registers and analyzed between Jan. 1, 1985, and Dec. 31, 2014. The average age of the participants at the study’s end was 25.1 years.

In all, 1,809 cardiovascular disease events were recorded over a median follow-up period of 14.9 years, for an incidence rate of 25.6 events per 10,000 person-years in patients and 22.6 events per 10,000 person-years in controls.

When separated by sex, the incidence was higher in female patients compared with controls (31.2 vs. 23.4 events per 10,000 person-years, respectively, but similar in male patients vs. controls (23.3 vs. 22.3 events per 10,000 person-years). “Differences in estrogen levels or responsiveness to rhGH treatment have previously been hypothesized as possible explanations, but the underlying mechanism for this sex difference still remains unclear and merits further investigation,” the researchers wrote.

Overall, the highest adjusted hazard ratios occurred in subgroups of patients with the longest treatment duration (HR 2.08) and highest cumulative dose of growth hormone (HR 2.05), but no association was noted between highest daily hormone dose and cardiovascular event risk. Hazard ratios were higher across all three treatment subgroups of SGA, GHD, and ISS compared with controls (HR 1.97, 1.66, and 1.55, respectively).

“The association between childhood rhGH treatment and CVD events was also seen when assessing only severe CVD outcomes, but with even lower absolute risks,” the researchers noted.

The study findings were limited by several factors including the potential for confounding by treatment indication and the lack of long-term follow-up data given the relatively young age of the study population, the researchers said. The results were strengthened by the large sample size and showed that the absolute risk for overall and severe cardiovascular disease in children treated with growth hormones was low, “which could be reassuring to individual patients,” they added. However, “At the group level, and perhaps especially for female patients and those treated for SGA indication, further close monitoring and future studies of CVD safety are warranted,” they concluded.
 

Safety and ethical concerns persist

Although the study authors cite limited conclusions on causality and low absolute risk, several issues persist that prompt ongoing analysis of pediatric growth hormone use, namely “worrisome indirect evidence, challenges and limitations in the direct evidence, and the changing world of growth hormone treatment,” Adda Grimberg, MD, of the University of Pennsylvania, Philadelphia, wrote in an accompanying editorial.

“Although evidence asserts that neither growth hormone nor insulinlike growth factor I is carcinogenic, the basic science and oncology literatures are rife with reports showing that they can make aberrant cells more aggressive,” and such indirect evidence supports the need for more direct evidence of possible harm from growth hormone treatment, Dr. Grimberg wrote. Most current safety data on growth hormone come from postmarketing surveillance studies, but these studies do not include controls or data on outcomes after discontinuation of treatment, she noted.

The current study, while able to follow patients across the lifespan, cannot indicate “whether the small but increased risk of cardiovascular disease found in this study was caused by the pediatric growth hormone treatment that identified the participants, by the conditions being treated, by other potential confounder(s) not captured by the study’s methods, or by a combination of the above,” said Dr. Grimberg.

In addition, “the move from replacement of GHD to pharmacologic height augmentation in children who already make sufficient growth hormone had the potential to change the safety profile of treatment,” she said.

“Parents of patients in pediatric primary care practices and of patients seeking growth-related care in a subspecialty endocrine clinic rated treatment characteristics (i.e., proven efficacy and safety) as the factor most having a big or extreme effect on their growth-related medical decision-making,” Dr. Grimberg said. “The centrality of treatment safety to patient-family decision-making underscores the importance of continued scrutiny of growth hormone safety as the treatment and its recipients continue to evolve,” she concluded.

The study was supported by the Swedish Research Council, the Stockholm City Council, the Karolinska Institute, the Society for Child Care, Sahlgrenska University Hospital, and the Stockholm County Council’s combined clinical residency and PhD training program. Lead author Dr. Tidblad disclosed funding from the Society for Child Care and Stockholm County Council during the conduct of the study and personal fees from Pfizer. Dr. Grimberg disclosed serving as a member of the steering committee for the Pfizer International Growth Study Database, and as a consultant for the Pediatric Endocrine Society GH Deficiency Knowledge Center, sponsored by Sandoz AG.

Moderna probably will not have clinical trial results anytime soon on how its COVID-19 vaccine affects children and adolescents, according to the company CEO and a federal official.

The Moderna vaccine was authorized for use in December and is now being given to people 18 and over. But children would receive lower doses, so new clinical trials must be done, Moderna CEO Stephane Bancel said at the JPMorgan virtual Health Care Conference on Monday.

Clinical trials on children 11 and younger “will take much longer, because we have to age deescalate and start at a lower dose. So we should not anticipate clinical data in 2021, but more in 2022,” Ms. Bancel said, according to Business Insider.

Moderna’s clinical trials for 12- to 17-year-olds started 4 weeks ago, but the company is having trouble getting enough participants, said Moncef Slaoui, PhD, the scientific head of Operation Warp Speed, the U.S. government’s vaccine effort. That could delay Food and Drug Administration approval, he said.

“It’s really very important for all of us, for all the population in America, to realize that we can’t have that indication unless adolescents aged 12-18 decide to participate,” Dr. Slaoui said, according to USA Today.

He said the adolescent trials are getting only about 800 volunteers a month, but need at least 3,000 volunteers to complete the study, USA Today reported. Parents interested in having their child participate can check eligibility and sign at this website.

The Pfizer/BioNTech vaccine won authorization for use in 16- to 17-year-olds as well as adults.

The coronavirus doesn’t appear to have as serious complications for children as for adults.

“At this time, it appears that severe illness due to COVID-19 is rare among children,” the American Association of Pediatrics says. “However, there is an urgent need to collect more data on longer-term impacts of the pandemic on children, including ways the virus may harm the long-term physical health of infected children, as well as its emotional and mental health effects.”

The association says 179 children had died of COVID-related reasons in 43 states and New York City as of Dec. 31, 2020. That’s about 0.06% of total COVID deaths, it says.

But children do get sick. As of Jan. 7, 2021, nearly 2.3 million children had tested positive for COVID-19 since the start of the pandemic, the association says.

A version of this article first appeared on WebMD.com.

Moderna probably will not have clinical trial results anytime soon on how its COVID-19 vaccine affects children and adolescents, according to the company CEO and a federal official.

The Moderna vaccine was authorized for use in December and is now being given to people 18 and over. But children would receive lower doses, so new clinical trials must be done, Moderna CEO Stephane Bancel said at the JPMorgan virtual Health Care Conference on Monday.

Clinical trials on children 11 and younger “will take much longer, because we have to age deescalate and start at a lower dose. So we should not anticipate clinical data in 2021, but more in 2022,” Ms. Bancel said, according to Business Insider.

Moderna’s clinical trials for 12- to 17-year-olds started 4 weeks ago, but the company is having trouble getting enough participants, said Moncef Slaoui, PhD, the scientific head of Operation Warp Speed, the U.S. government’s vaccine effort. That could delay Food and Drug Administration approval, he said.

“It’s really very important for all of us, for all the population in America, to realize that we can’t have that indication unless adolescents aged 12-18 decide to participate,” Dr. Slaoui said, according to USA Today.

He said the adolescent trials are getting only about 800 volunteers a month, but need at least 3,000 volunteers to complete the study, USA Today reported. Parents interested in having their child participate can check eligibility and sign at this website.

The Pfizer/BioNTech vaccine won authorization for use in 16- to 17-year-olds as well as adults.

The coronavirus doesn’t appear to have as serious complications for children as for adults.

“At this time, it appears that severe illness due to COVID-19 is rare among children,” the American Association of Pediatrics says. “However, there is an urgent need to collect more data on longer-term impacts of the pandemic on children, including ways the virus may harm the long-term physical health of infected children, as well as its emotional and mental health effects.”

The association says 179 children had died of COVID-related reasons in 43 states and New York City as of Dec. 31, 2020. That’s about 0.06% of total COVID deaths, it says.

But children do get sick. As of Jan. 7, 2021, nearly 2.3 million children had tested positive for COVID-19 since the start of the pandemic, the association says.

A version of this article first appeared on WebMD.com.

Moderna probably will not have clinical trial results anytime soon on how its COVID-19 vaccine affects children and adolescents, according to the company CEO and a federal official.

The Moderna vaccine was authorized for use in December and is now being given to people 18 and over. But children would receive lower doses, so new clinical trials must be done, Moderna CEO Stephane Bancel said at the JPMorgan virtual Health Care Conference on Monday.

Clinical trials on children 11 and younger “will take much longer, because we have to age deescalate and start at a lower dose. So we should not anticipate clinical data in 2021, but more in 2022,” Ms. Bancel said, according to Business Insider.

Moderna’s clinical trials for 12- to 17-year-olds started 4 weeks ago, but the company is having trouble getting enough participants, said Moncef Slaoui, PhD, the scientific head of Operation Warp Speed, the U.S. government’s vaccine effort. That could delay Food and Drug Administration approval, he said.

“It’s really very important for all of us, for all the population in America, to realize that we can’t have that indication unless adolescents aged 12-18 decide to participate,” Dr. Slaoui said, according to USA Today.

He said the adolescent trials are getting only about 800 volunteers a month, but need at least 3,000 volunteers to complete the study, USA Today reported. Parents interested in having their child participate can check eligibility and sign at this website.

The Pfizer/BioNTech vaccine won authorization for use in 16- to 17-year-olds as well as adults.

The coronavirus doesn’t appear to have as serious complications for children as for adults.

“At this time, it appears that severe illness due to COVID-19 is rare among children,” the American Association of Pediatrics says. “However, there is an urgent need to collect more data on longer-term impacts of the pandemic on children, including ways the virus may harm the long-term physical health of infected children, as well as its emotional and mental health effects.”

The association says 179 children had died of COVID-related reasons in 43 states and New York City as of Dec. 31, 2020. That’s about 0.06% of total COVID deaths, it says.

But children do get sick. As of Jan. 7, 2021, nearly 2.3 million children had tested positive for COVID-19 since the start of the pandemic, the association says.

A version of this article first appeared on WebMD.com.

The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.

Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.

AscentXmedia/E+

The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.

There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.

If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] .

The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.

Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.

AscentXmedia/E+

The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.

There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.

If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] .

The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.

Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.

AscentXmedia/E+

The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.

There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.

If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] .

When Margot Gage-Witvliet began feeling run down after her family returned from a trip to the Netherlands in late February 2020, she initially chalked up her symptoms to jet lag. Three days later, however, her situation went from concerning to alarming as she struggled to breathe. “It felt like there was an elephant sitting on my chest,” she said.

Her husband and daughters also became ill with COVID-19, but Ms. Gage-Witvliet was the only one in her family who didn’t get better. After an early improvement, a rare coronavirus-induced tonic-clonic seizure in early April sent her spiraling back down. Ms. Gage-Witvliet spent the next several weeks in bed with the curtains drawn, unable to tolerate light or sound.

Today, Ms. Gage-Witvliet’s life looks nothing like it did 6 months ago when she first got sick. As one of COVID-19’s so called long-haulers, she continues to struggle with crushing fatigue, brain fog, and headaches – symptoms that worsen when she pushes herself to do more. Across the country, as many as 1 in 10 COVID-19 patients are reporting illnesses that continue for weeks and months after their initial diagnosis. Nearly all report neurologic issues like Ms. Gage-Witvliet, as well as shortness of breath and psychiatric concerns.

For Avindra Nath, MD, a neurologist at the National Institutes of Health, the experience of these long-haul COVID-19 patients feels familiar and reminds him of myalgic encephalomyelitis, also known as chronic fatigue syndrome.

Dr. Nath has long been interested in the lingering neurologic issues connected to chronic fatigue. An estimated three-quarters of all patients with chronic fatigue syndrome report that their symptoms started after a viral infection, and they suffer unrelenting exhaustion, difficulties regulating pulse and blood pressure, aches and pains, and brain fog. When Dr. Nath first read about the novel coronavirus, he began to worry that the virus would trigger symptoms in a subset of those infected. Hearing about the experiences of long-haulers like Ms. Gage-Witvliet raised his suspicions even more.

Unlike COVID-19 long-haulers, however, many patients with chronic fatigue syndrome go at least a year with these symptoms before receiving a diagnosis, according to a British survey. That means researchers have had few opportunities to study the early stages of the syndrome. “When we see patients with myalgic encephalomyelitis, whatever infection they might have had occurred in the remote past, so there’s no way for us to know how they got infected with it, what the infection was, or what the effects of it were in that early phase. We’re seeing them 2 years afterward,” Dr. Nath said.

Dr. Nath quickly realized that studying patients like Ms. Gage-Witvliet would give physicians and scientists a unique opportunity to understand not only long-term outcomes of COVID-19 infections, but also other postviral syndromes, including chronic fatigue syndrome at their earliest stages. It’s why Dr. Nath has spent the past several months scrambling to launch two NIH studies to examine the phenomenon.

Although Dr. Nath said that the parallels between COVID-19 long-haulers and those with chronic fatigue syndrome are obvious, he cautions against assuming that they are the same phenomenon. Some long-haulers might simply be taking a much slower path to recovery, or they might have a condition that looks similar on the surface but differs from chronic fatigue syndrome on a molecular level. But even if Dr. Nath fails to see links to chronic fatigue syndrome, with more than 92.5 million documented cases of COVID-19 around the world, the work will be relevant to the substantial number of infected individuals who don’t recover quickly.

“With so many people having exposure to the same virus over a similar time period, we really have the opportunity to look at these manifestations and at the very least to understand postviral syndromes,” said Mady Hornig, MD, a psychiatrist at Columbia University, New York.

The origins of chronic fatigue syndrome date back to 1985, when the Centers for Disease Control and Prevention received a request from two physicians – Paul Cheney, MD, and Daniel Peterson, MD – to investigate a mysterious disease outbreak in Nevada. In November 1984, residents in and around the idyllic vacation spot of Incline Village, a small town tucked into the north shore of Lake Tahoe, had begun reporting flu-like symptoms that persisted for weeks, even months. The doctors had searched high and low for a cause, but they couldn’t figure out what was making their patients sick.

They reported a range of symptoms – including muscle aches and pains, low-grade fevers, sore throats, and headaches – but everyone said that crippling fatigue was the most debilitating issue. This wasn’t the kind of fatigue that could be cured by a nap or even a long holiday. No matter how much their patients slept – and some were almost completely bedbound – their fatigue didn’t abate. What’s more, the fatigue got worse whenever they tried to push themselves to do more. Puzzled, the CDC sent two epidemic intelligence service (EIS) officers to try to get to the bottom of what might be happening.


 

Muscle aches and pains with crippling fatigue

After their visit to Incline Village, however, the CDC was just as perplexed as Dr. Cheney and Dr. Peterson. Many of the people with the condition reported flu-like symptoms right around the time they first got sick, and the physicians’ leading hypothesis was that the outbreak and its lasting symptoms were caused by chronic Epstein-Barr virus infection. But neither the CDC nor anyone else could identify the infection or any other microbial cause. The two EIS officers duly wrote up a report for the CDC’s flagship publication, Morbidity and Mortality Weekly ReportI, titled “Chronic Fatigue Possibly Related to Epstein-Barr Virus – Nevada”.

That investigators focused on the fatigue aspect made sense, says Leonard A. Jason, PhD, professor of psychology at DePaul University and director of the Center for Community Research, both in Chicago, because it was one of the few symptoms shared by all the individuals studied and it was also the most debilitating. But that focus – and the name “chronic fatigue syndrome” – led to broad public dismissal of the condition’s severity, as did an editorial note in MMWR urging physicians to look for “more definable, and possibly treatable, conditions.” Subsequent research failed to confirm a specific link to the Epstein-Barr virus, which only added to the condition’s phony reputation. Rather than being considered a potentially disabling illness, it was disregarded as a “yuppie flu” or a fancy name for malingering.

“It’s not a surprise that patients are being dismissed because there’s already this sort of grandfathered-in sense that fatigue is not real,” said Jennifer Frankovich, MD, a pediatric rheumatologist at Stanford (Calif.) University’s Lucile Packard Children’s Hospital in Palo Alto. “I’m sure that’s frustrating for them to be tired and then to have the clinician not believe them or dismiss them or think they’re making it up. It would be more helpful to the families to say: ‘You know what, we don’t know, we do not have the answer, and we believe you.’ ”
 

A syndrome’s shame

As time passed, patient advocacy groups began pushing back against the negative way the condition was being perceived. This criticism came as organizations like the CDC worked to develop a set of diagnostic criteria that researchers and clinicians dealing with chronic fatigue syndrome could use. With such a heterogeneous group of patients and symptoms, the task was no small challenge. The discussions, which took place over nearly 2 decades, played a key role in helping scientists home in on the single factor that was central to chronic fatigue: postexertional malaise.

“This is quite unique for chronic fatigue syndrome. With other diseases, yes, you may have fatigue as one of the components of the disease, but postexertional fatigue is very specific,” said Alain Moreau, PhD, a molecular biologist at the University of Montreal.

Of course, plenty of people have pushed themselves too hard physically and paid the price the next day. But those with chronic fatigue syndrome weren’t running marathons. To them, exertion could be anything from getting the mail to reading a book. Nor could the resulting exhaustion be resolved by an afternoon on the couch or a long vacation.

“If they do these activities, they can crash for weeks, even months,” Dr. Moreau said. It was deep, persistent, and – for 40% of those with chronic fatigue syndrome – disabling. In 2015, a study group from the Institute of Medicine proposed renaming chronic fatigue to “systemic exercise intolerance disease” because of the centrality of this symptom. Although that effort mostly stalled, their report did bring the condition out of its historic place as a scientific backwater. What resulted was an uptick in research on chronic fatigue syndrome, which helped define some of the physiological issues that either contribute to or result from the condition.

Researchers had long known about the link between infection and fatigue, said Dr. Frankovich. Work included mysterious outbreaks like the one in Lake Tahoe and well-documented issues like the wave of encephalitis lethargica (a condition that leaves patients in an almost vegetative state) that followed the 1918 H1N1 influenza pandemic.

“As a clinician, when you see someone who comes in with a chronic infection, they’re tired. I think that’s why, in the chronic-fatigue world, people are desperately looking for the infection so we can treat it, and maybe these poor suffering people will feel better,” Dr. Frankovich added. Then the pandemic struck, giving him yet another opportunity to study postviral syndromes.
 

Immunologic symptoms

Given the close link between a nonspecific viral illness and the onset of symptoms in chronic fatigue syndrome, scientists like Dr. Hornig opted to focus on immunologic symptoms. In a 2015 analysis published in Science, Dr. Hornig and colleagues showed that immune problems can be found in the earliest stages of chronic fatigue syndrome, and that they change as the illness progresses. Patients who had been sick for less than 3 years showed significant increases in levels of both pro- and anti-inflammatory cytokines, and the factor most strongly correlated to this inability to regulate cytokine levels was the duration of symptoms, not their severity. A series of other studies also revealed problems with regulation of the immune system, although no one could show what might have set these problems in motion.

Other researchers found signs of mitochondrial dysfunction in those with chronic fatigue syndrome. Because mitochondria make energy for cells, it wasn’t an intellectual stretch to believe that glitches in this process could contribute to fatigue. As early as 1991, scientists had discovered signs of mitochondrial degeneration in muscle biopsies from people with chronic fatigue syndrome. Subsequent studies showed that those affected by chronic fatigue were missing segments of mitochondrial DNA and had significantly reduced levels of mitochondrial activity. Although exercise normally improves mitochondrial functioning, the opposite appears to happen in chronic fatigue.

To Dr. Nath, these dual hypotheses aren’t necessarily mutually exclusive. Some studies have hinted that infection with the common human herpesvirus–6 (HHV-6) can lead to an autoimmune condition in which the body makes antibodies against the mitochondria. Mitochondria also play a key role in the ability of the innate immune system to produce interferon and other proinflammatory cytokines. It might also be that the link between immune and mitochondrial problems is more convoluted than originally thought, or that the two systems are affected independent of one another, Dr. Nath said.

Finding answers, especially those that could lead to potential treatments, wouldn’t be easy, however. In 2016, the NIH launched an in-depth study of a small number of individuals with chronic fatigue, hoping to find clues about what the condition was and how it might be treated.

For scientists like Dr. Nath, the NIH study provided a way to get at the underlying biology of chronic fatigue syndrome. Then the pandemic struck, giving him yet another opportunity to study postviral syndromes.
 

Chronic post-SARS syndrome

In March 2020, retired physician Harvey Moldofsky, MD, began receiving inquiries about a 2011 study he and his colleague, John Patcai, MD, had published in BMC Neurology about something they dubbed “chronic post-SARS syndrome.” The small case-control study, which involved mainly health care workers in Toronto, received little attention when it was first published, but with COVID-19, it was suddenly relevant.

Early clusters of similar cases in Miami made local physicians desperate for Dr. Moldofsky’s expertise. Luckily, he was nearby; he had fled the frigid Canadian winter for the warmth of Sarasota, Fla.

“I had people from various countries around the world writing to me and asking what they should do. And of course I don’t have any answers,” he said. But the study contained one of the world’s only references to the syndrome.

In 2003, a woman arrived in Toronto from Hong Kong. She didn’t know it at the time, but her preairport stay at the Hotel Metropole had infected her with the first SARS (severe acute respiratory syndrome) coronavirus. Her subsequent hospitalization in Toronto sparked a city-wide outbreak of SARS in which 273 people became ill and 44 died. Many of those affected were health care workers, including nurses and respiratory therapists. Although most eventually returned to work, a subset couldn’t. They complained of energy-sapping fatigue, poor sleep, brain fog, and assorted body aches and pains that persisted for more than 18 months. The aches and pains brought them to the attention of Dr. Moldofsky, then director of the Centre for the Study of Pain at the University of Toronto.

His primary interest at the time was fibromyalgia, which caused symptoms similar to those reported by the original SARS long-haulers. Intrigued, Dr. Moldofsky agreed to take a look. Their chest x-rays were clear and the nurses showed no signs of lingering viral infection. Dr. Moldofsky could see that the nurses were ill and suffering, but no lab tests or anything else could identify what was causing their symptoms.

In 2011, Dr. Moldofsky and Dr. Patcai found a strong overlap between chronic SARS, fibromyalgia, and chronic fatigue syndrome when they compared 22 patients with long-term SARS issues with 21 who had fibromyalgia. “Their problems are exactly the same. They have strange symptoms and nobody can figure out what they’re about. And these symptoms are aches and pains, and they have trouble thinking and concentrating,” Dr. Moldofsky said. Reports of COVID-19 long-haulers didn’t surprise Dr. Moldofsky, and he immediately recognized that Nath’s intention to follow these patients could provide insights into both fibromyalgia and chronic fatigue syndrome.

That’s exactly what Dr. Nath is proposing with the two NIH studies. One will focus solely on the neurologic impacts of COVID-19, including stroke, loss of taste and smell, and brain fog. The other will bring patients who have had COVID-19 symptoms for at least 6 months to the NIH Clinical Center for an inpatient stay during which they will undergo detailed physiologic tests.

Scientists around the world are launching their own post–COVID-19 studies. Dr. Moreau’s group in Montreal has laid the groundwork for such an endeavor, and the CoroNerve group in the United Kingdom is monitoring neurologic complications from the coronavirus. Many of them have the same goals as the NIH studies: Leverage the large number of COVID-19 long-haulers to better understand the earliest stages of postviral syndrome.

“At this juncture, after all the reports that we’ve seen so far, I think it’s very unlikely that there will be no relationship whatsoever between COVID-19 and chronic fatigue syndrome,” Dr. Hornig said. “I think there certainly will be some, but again, what’s the scope, what’s the size? And then, of course, even more importantly, if it is happening, what is the mechanism and how is it happening?”

For people like Ms. Gage-Witvliet, the answers can’t come soon enough. For the first time in more than a decade, the full-time professor of epidemiology didn’t prepare to teach this year because she simply can’t. It’s too taxing for her brain to deal with impromptu student questions. Ms. Gage-Witvliet hopes that, by sharing her own experiences with post COVID-19, she can help others.

“In my work, I use data to give a voice to people who don’t have a voice,” she said. “Now, I am one of those people.”

A version of this article first appeared on Medscape.com.

When Margot Gage-Witvliet began feeling run down after her family returned from a trip to the Netherlands in late February 2020, she initially chalked up her symptoms to jet lag. Three days later, however, her situation went from concerning to alarming as she struggled to breathe. “It felt like there was an elephant sitting on my chest,” she said.

Her husband and daughters also became ill with COVID-19, but Ms. Gage-Witvliet was the only one in her family who didn’t get better. After an early improvement, a rare coronavirus-induced tonic-clonic seizure in early April sent her spiraling back down. Ms. Gage-Witvliet spent the next several weeks in bed with the curtains drawn, unable to tolerate light or sound.

Today, Ms. Gage-Witvliet’s life looks nothing like it did 6 months ago when she first got sick. As one of COVID-19’s so called long-haulers, she continues to struggle with crushing fatigue, brain fog, and headaches – symptoms that worsen when she pushes herself to do more. Across the country, as many as 1 in 10 COVID-19 patients are reporting illnesses that continue for weeks and months after their initial diagnosis. Nearly all report neurologic issues like Ms. Gage-Witvliet, as well as shortness of breath and psychiatric concerns.

For Avindra Nath, MD, a neurologist at the National Institutes of Health, the experience of these long-haul COVID-19 patients feels familiar and reminds him of myalgic encephalomyelitis, also known as chronic fatigue syndrome.

Dr. Nath has long been interested in the lingering neurologic issues connected to chronic fatigue. An estimated three-quarters of all patients with chronic fatigue syndrome report that their symptoms started after a viral infection, and they suffer unrelenting exhaustion, difficulties regulating pulse and blood pressure, aches and pains, and brain fog. When Dr. Nath first read about the novel coronavirus, he began to worry that the virus would trigger symptoms in a subset of those infected. Hearing about the experiences of long-haulers like Ms. Gage-Witvliet raised his suspicions even more.

Unlike COVID-19 long-haulers, however, many patients with chronic fatigue syndrome go at least a year with these symptoms before receiving a diagnosis, according to a British survey. That means researchers have had few opportunities to study the early stages of the syndrome. “When we see patients with myalgic encephalomyelitis, whatever infection they might have had occurred in the remote past, so there’s no way for us to know how they got infected with it, what the infection was, or what the effects of it were in that early phase. We’re seeing them 2 years afterward,” Dr. Nath said.

Dr. Nath quickly realized that studying patients like Ms. Gage-Witvliet would give physicians and scientists a unique opportunity to understand not only long-term outcomes of COVID-19 infections, but also other postviral syndromes, including chronic fatigue syndrome at their earliest stages. It’s why Dr. Nath has spent the past several months scrambling to launch two NIH studies to examine the phenomenon.

Although Dr. Nath said that the parallels between COVID-19 long-haulers and those with chronic fatigue syndrome are obvious, he cautions against assuming that they are the same phenomenon. Some long-haulers might simply be taking a much slower path to recovery, or they might have a condition that looks similar on the surface but differs from chronic fatigue syndrome on a molecular level. But even if Dr. Nath fails to see links to chronic fatigue syndrome, with more than 92.5 million documented cases of COVID-19 around the world, the work will be relevant to the substantial number of infected individuals who don’t recover quickly.

“With so many people having exposure to the same virus over a similar time period, we really have the opportunity to look at these manifestations and at the very least to understand postviral syndromes,” said Mady Hornig, MD, a psychiatrist at Columbia University, New York.

The origins of chronic fatigue syndrome date back to 1985, when the Centers for Disease Control and Prevention received a request from two physicians – Paul Cheney, MD, and Daniel Peterson, MD – to investigate a mysterious disease outbreak in Nevada. In November 1984, residents in and around the idyllic vacation spot of Incline Village, a small town tucked into the north shore of Lake Tahoe, had begun reporting flu-like symptoms that persisted for weeks, even months. The doctors had searched high and low for a cause, but they couldn’t figure out what was making their patients sick.

They reported a range of symptoms – including muscle aches and pains, low-grade fevers, sore throats, and headaches – but everyone said that crippling fatigue was the most debilitating issue. This wasn’t the kind of fatigue that could be cured by a nap or even a long holiday. No matter how much their patients slept – and some were almost completely bedbound – their fatigue didn’t abate. What’s more, the fatigue got worse whenever they tried to push themselves to do more. Puzzled, the CDC sent two epidemic intelligence service (EIS) officers to try to get to the bottom of what might be happening.


 

Muscle aches and pains with crippling fatigue

After their visit to Incline Village, however, the CDC was just as perplexed as Dr. Cheney and Dr. Peterson. Many of the people with the condition reported flu-like symptoms right around the time they first got sick, and the physicians’ leading hypothesis was that the outbreak and its lasting symptoms were caused by chronic Epstein-Barr virus infection. But neither the CDC nor anyone else could identify the infection or any other microbial cause. The two EIS officers duly wrote up a report for the CDC’s flagship publication, Morbidity and Mortality Weekly ReportI, titled “Chronic Fatigue Possibly Related to Epstein-Barr Virus – Nevada”.

That investigators focused on the fatigue aspect made sense, says Leonard A. Jason, PhD, professor of psychology at DePaul University and director of the Center for Community Research, both in Chicago, because it was one of the few symptoms shared by all the individuals studied and it was also the most debilitating. But that focus – and the name “chronic fatigue syndrome” – led to broad public dismissal of the condition’s severity, as did an editorial note in MMWR urging physicians to look for “more definable, and possibly treatable, conditions.” Subsequent research failed to confirm a specific link to the Epstein-Barr virus, which only added to the condition’s phony reputation. Rather than being considered a potentially disabling illness, it was disregarded as a “yuppie flu” or a fancy name for malingering.

“It’s not a surprise that patients are being dismissed because there’s already this sort of grandfathered-in sense that fatigue is not real,” said Jennifer Frankovich, MD, a pediatric rheumatologist at Stanford (Calif.) University’s Lucile Packard Children’s Hospital in Palo Alto. “I’m sure that’s frustrating for them to be tired and then to have the clinician not believe them or dismiss them or think they’re making it up. It would be more helpful to the families to say: ‘You know what, we don’t know, we do not have the answer, and we believe you.’ ”
 

A syndrome’s shame

As time passed, patient advocacy groups began pushing back against the negative way the condition was being perceived. This criticism came as organizations like the CDC worked to develop a set of diagnostic criteria that researchers and clinicians dealing with chronic fatigue syndrome could use. With such a heterogeneous group of patients and symptoms, the task was no small challenge. The discussions, which took place over nearly 2 decades, played a key role in helping scientists home in on the single factor that was central to chronic fatigue: postexertional malaise.

“This is quite unique for chronic fatigue syndrome. With other diseases, yes, you may have fatigue as one of the components of the disease, but postexertional fatigue is very specific,” said Alain Moreau, PhD, a molecular biologist at the University of Montreal.

Of course, plenty of people have pushed themselves too hard physically and paid the price the next day. But those with chronic fatigue syndrome weren’t running marathons. To them, exertion could be anything from getting the mail to reading a book. Nor could the resulting exhaustion be resolved by an afternoon on the couch or a long vacation.

“If they do these activities, they can crash for weeks, even months,” Dr. Moreau said. It was deep, persistent, and – for 40% of those with chronic fatigue syndrome – disabling. In 2015, a study group from the Institute of Medicine proposed renaming chronic fatigue to “systemic exercise intolerance disease” because of the centrality of this symptom. Although that effort mostly stalled, their report did bring the condition out of its historic place as a scientific backwater. What resulted was an uptick in research on chronic fatigue syndrome, which helped define some of the physiological issues that either contribute to or result from the condition.

Researchers had long known about the link between infection and fatigue, said Dr. Frankovich. Work included mysterious outbreaks like the one in Lake Tahoe and well-documented issues like the wave of encephalitis lethargica (a condition that leaves patients in an almost vegetative state) that followed the 1918 H1N1 influenza pandemic.

“As a clinician, when you see someone who comes in with a chronic infection, they’re tired. I think that’s why, in the chronic-fatigue world, people are desperately looking for the infection so we can treat it, and maybe these poor suffering people will feel better,” Dr. Frankovich added. Then the pandemic struck, giving him yet another opportunity to study postviral syndromes.
 

Immunologic symptoms

Given the close link between a nonspecific viral illness and the onset of symptoms in chronic fatigue syndrome, scientists like Dr. Hornig opted to focus on immunologic symptoms. In a 2015 analysis published in Science, Dr. Hornig and colleagues showed that immune problems can be found in the earliest stages of chronic fatigue syndrome, and that they change as the illness progresses. Patients who had been sick for less than 3 years showed significant increases in levels of both pro- and anti-inflammatory cytokines, and the factor most strongly correlated to this inability to regulate cytokine levels was the duration of symptoms, not their severity. A series of other studies also revealed problems with regulation of the immune system, although no one could show what might have set these problems in motion.

Other researchers found signs of mitochondrial dysfunction in those with chronic fatigue syndrome. Because mitochondria make energy for cells, it wasn’t an intellectual stretch to believe that glitches in this process could contribute to fatigue. As early as 1991, scientists had discovered signs of mitochondrial degeneration in muscle biopsies from people with chronic fatigue syndrome. Subsequent studies showed that those affected by chronic fatigue were missing segments of mitochondrial DNA and had significantly reduced levels of mitochondrial activity. Although exercise normally improves mitochondrial functioning, the opposite appears to happen in chronic fatigue.

To Dr. Nath, these dual hypotheses aren’t necessarily mutually exclusive. Some studies have hinted that infection with the common human herpesvirus–6 (HHV-6) can lead to an autoimmune condition in which the body makes antibodies against the mitochondria. Mitochondria also play a key role in the ability of the innate immune system to produce interferon and other proinflammatory cytokines. It might also be that the link between immune and mitochondrial problems is more convoluted than originally thought, or that the two systems are affected independent of one another, Dr. Nath said.

Finding answers, especially those that could lead to potential treatments, wouldn’t be easy, however. In 2016, the NIH launched an in-depth study of a small number of individuals with chronic fatigue, hoping to find clues about what the condition was and how it might be treated.

For scientists like Dr. Nath, the NIH study provided a way to get at the underlying biology of chronic fatigue syndrome. Then the pandemic struck, giving him yet another opportunity to study postviral syndromes.
 

Chronic post-SARS syndrome

In March 2020, retired physician Harvey Moldofsky, MD, began receiving inquiries about a 2011 study he and his colleague, John Patcai, MD, had published in BMC Neurology about something they dubbed “chronic post-SARS syndrome.” The small case-control study, which involved mainly health care workers in Toronto, received little attention when it was first published, but with COVID-19, it was suddenly relevant.

Early clusters of similar cases in Miami made local physicians desperate for Dr. Moldofsky’s expertise. Luckily, he was nearby; he had fled the frigid Canadian winter for the warmth of Sarasota, Fla.

“I had people from various countries around the world writing to me and asking what they should do. And of course I don’t have any answers,” he said. But the study contained one of the world’s only references to the syndrome.

In 2003, a woman arrived in Toronto from Hong Kong. She didn’t know it at the time, but her preairport stay at the Hotel Metropole had infected her with the first SARS (severe acute respiratory syndrome) coronavirus. Her subsequent hospitalization in Toronto sparked a city-wide outbreak of SARS in which 273 people became ill and 44 died. Many of those affected were health care workers, including nurses and respiratory therapists. Although most eventually returned to work, a subset couldn’t. They complained of energy-sapping fatigue, poor sleep, brain fog, and assorted body aches and pains that persisted for more than 18 months. The aches and pains brought them to the attention of Dr. Moldofsky, then director of the Centre for the Study of Pain at the University of Toronto.

His primary interest at the time was fibromyalgia, which caused symptoms similar to those reported by the original SARS long-haulers. Intrigued, Dr. Moldofsky agreed to take a look. Their chest x-rays were clear and the nurses showed no signs of lingering viral infection. Dr. Moldofsky could see that the nurses were ill and suffering, but no lab tests or anything else could identify what was causing their symptoms.

In 2011, Dr. Moldofsky and Dr. Patcai found a strong overlap between chronic SARS, fibromyalgia, and chronic fatigue syndrome when they compared 22 patients with long-term SARS issues with 21 who had fibromyalgia. “Their problems are exactly the same. They have strange symptoms and nobody can figure out what they’re about. And these symptoms are aches and pains, and they have trouble thinking and concentrating,” Dr. Moldofsky said. Reports of COVID-19 long-haulers didn’t surprise Dr. Moldofsky, and he immediately recognized that Nath’s intention to follow these patients could provide insights into both fibromyalgia and chronic fatigue syndrome.

That’s exactly what Dr. Nath is proposing with the two NIH studies. One will focus solely on the neurologic impacts of COVID-19, including stroke, loss of taste and smell, and brain fog. The other will bring patients who have had COVID-19 symptoms for at least 6 months to the NIH Clinical Center for an inpatient stay during which they will undergo detailed physiologic tests.

Scientists around the world are launching their own post–COVID-19 studies. Dr. Moreau’s group in Montreal has laid the groundwork for such an endeavor, and the CoroNerve group in the United Kingdom is monitoring neurologic complications from the coronavirus. Many of them have the same goals as the NIH studies: Leverage the large number of COVID-19 long-haulers to better understand the earliest stages of postviral syndrome.

“At this juncture, after all the reports that we’ve seen so far, I think it’s very unlikely that there will be no relationship whatsoever between COVID-19 and chronic fatigue syndrome,” Dr. Hornig said. “I think there certainly will be some, but again, what’s the scope, what’s the size? And then, of course, even more importantly, if it is happening, what is the mechanism and how is it happening?”

For people like Ms. Gage-Witvliet, the answers can’t come soon enough. For the first time in more than a decade, the full-time professor of epidemiology didn’t prepare to teach this year because she simply can’t. It’s too taxing for her brain to deal with impromptu student questions. Ms. Gage-Witvliet hopes that, by sharing her own experiences with post COVID-19, she can help others.

“In my work, I use data to give a voice to people who don’t have a voice,” she said. “Now, I am one of those people.”

A version of this article first appeared on Medscape.com.

When Margot Gage-Witvliet began feeling run down after her family returned from a trip to the Netherlands in late February 2020, she initially chalked up her symptoms to jet lag. Three days later, however, her situation went from concerning to alarming as she struggled to breathe. “It felt like there was an elephant sitting on my chest,” she said.

Her husband and daughters also became ill with COVID-19, but Ms. Gage-Witvliet was the only one in her family who didn’t get better. After an early improvement, a rare coronavirus-induced tonic-clonic seizure in early April sent her spiraling back down. Ms. Gage-Witvliet spent the next several weeks in bed with the curtains drawn, unable to tolerate light or sound.

Today, Ms. Gage-Witvliet’s life looks nothing like it did 6 months ago when she first got sick. As one of COVID-19’s so called long-haulers, she continues to struggle with crushing fatigue, brain fog, and headaches – symptoms that worsen when she pushes herself to do more. Across the country, as many as 1 in 10 COVID-19 patients are reporting illnesses that continue for weeks and months after their initial diagnosis. Nearly all report neurologic issues like Ms. Gage-Witvliet, as well as shortness of breath and psychiatric concerns.

For Avindra Nath, MD, a neurologist at the National Institutes of Health, the experience of these long-haul COVID-19 patients feels familiar and reminds him of myalgic encephalomyelitis, also known as chronic fatigue syndrome.

Dr. Nath has long been interested in the lingering neurologic issues connected to chronic fatigue. An estimated three-quarters of all patients with chronic fatigue syndrome report that their symptoms started after a viral infection, and they suffer unrelenting exhaustion, difficulties regulating pulse and blood pressure, aches and pains, and brain fog. When Dr. Nath first read about the novel coronavirus, he began to worry that the virus would trigger symptoms in a subset of those infected. Hearing about the experiences of long-haulers like Ms. Gage-Witvliet raised his suspicions even more.

Unlike COVID-19 long-haulers, however, many patients with chronic fatigue syndrome go at least a year with these symptoms before receiving a diagnosis, according to a British survey. That means researchers have had few opportunities to study the early stages of the syndrome. “When we see patients with myalgic encephalomyelitis, whatever infection they might have had occurred in the remote past, so there’s no way for us to know how they got infected with it, what the infection was, or what the effects of it were in that early phase. We’re seeing them 2 years afterward,” Dr. Nath said.

Dr. Nath quickly realized that studying patients like Ms. Gage-Witvliet would give physicians and scientists a unique opportunity to understand not only long-term outcomes of COVID-19 infections, but also other postviral syndromes, including chronic fatigue syndrome at their earliest stages. It’s why Dr. Nath has spent the past several months scrambling to launch two NIH studies to examine the phenomenon.

Although Dr. Nath said that the parallels between COVID-19 long-haulers and those with chronic fatigue syndrome are obvious, he cautions against assuming that they are the same phenomenon. Some long-haulers might simply be taking a much slower path to recovery, or they might have a condition that looks similar on the surface but differs from chronic fatigue syndrome on a molecular level. But even if Dr. Nath fails to see links to chronic fatigue syndrome, with more than 92.5 million documented cases of COVID-19 around the world, the work will be relevant to the substantial number of infected individuals who don’t recover quickly.

“With so many people having exposure to the same virus over a similar time period, we really have the opportunity to look at these manifestations and at the very least to understand postviral syndromes,” said Mady Hornig, MD, a psychiatrist at Columbia University, New York.

The origins of chronic fatigue syndrome date back to 1985, when the Centers for Disease Control and Prevention received a request from two physicians – Paul Cheney, MD, and Daniel Peterson, MD – to investigate a mysterious disease outbreak in Nevada. In November 1984, residents in and around the idyllic vacation spot of Incline Village, a small town tucked into the north shore of Lake Tahoe, had begun reporting flu-like symptoms that persisted for weeks, even months. The doctors had searched high and low for a cause, but they couldn’t figure out what was making their patients sick.

They reported a range of symptoms – including muscle aches and pains, low-grade fevers, sore throats, and headaches – but everyone said that crippling fatigue was the most debilitating issue. This wasn’t the kind of fatigue that could be cured by a nap or even a long holiday. No matter how much their patients slept – and some were almost completely bedbound – their fatigue didn’t abate. What’s more, the fatigue got worse whenever they tried to push themselves to do more. Puzzled, the CDC sent two epidemic intelligence service (EIS) officers to try to get to the bottom of what might be happening.


 

Muscle aches and pains with crippling fatigue

After their visit to Incline Village, however, the CDC was just as perplexed as Dr. Cheney and Dr. Peterson. Many of the people with the condition reported flu-like symptoms right around the time they first got sick, and the physicians’ leading hypothesis was that the outbreak and its lasting symptoms were caused by chronic Epstein-Barr virus infection. But neither the CDC nor anyone else could identify the infection or any other microbial cause. The two EIS officers duly wrote up a report for the CDC’s flagship publication, Morbidity and Mortality Weekly ReportI, titled “Chronic Fatigue Possibly Related to Epstein-Barr Virus – Nevada”.

That investigators focused on the fatigue aspect made sense, says Leonard A. Jason, PhD, professor of psychology at DePaul University and director of the Center for Community Research, both in Chicago, because it was one of the few symptoms shared by all the individuals studied and it was also the most debilitating. But that focus – and the name “chronic fatigue syndrome” – led to broad public dismissal of the condition’s severity, as did an editorial note in MMWR urging physicians to look for “more definable, and possibly treatable, conditions.” Subsequent research failed to confirm a specific link to the Epstein-Barr virus, which only added to the condition’s phony reputation. Rather than being considered a potentially disabling illness, it was disregarded as a “yuppie flu” or a fancy name for malingering.

“It’s not a surprise that patients are being dismissed because there’s already this sort of grandfathered-in sense that fatigue is not real,” said Jennifer Frankovich, MD, a pediatric rheumatologist at Stanford (Calif.) University’s Lucile Packard Children’s Hospital in Palo Alto. “I’m sure that’s frustrating for them to be tired and then to have the clinician not believe them or dismiss them or think they’re making it up. It would be more helpful to the families to say: ‘You know what, we don’t know, we do not have the answer, and we believe you.’ ”
 

A syndrome’s shame

As time passed, patient advocacy groups began pushing back against the negative way the condition was being perceived. This criticism came as organizations like the CDC worked to develop a set of diagnostic criteria that researchers and clinicians dealing with chronic fatigue syndrome could use. With such a heterogeneous group of patients and symptoms, the task was no small challenge. The discussions, which took place over nearly 2 decades, played a key role in helping scientists home in on the single factor that was central to chronic fatigue: postexertional malaise.

“This is quite unique for chronic fatigue syndrome. With other diseases, yes, you may have fatigue as one of the components of the disease, but postexertional fatigue is very specific,” said Alain Moreau, PhD, a molecular biologist at the University of Montreal.

Of course, plenty of people have pushed themselves too hard physically and paid the price the next day. But those with chronic fatigue syndrome weren’t running marathons. To them, exertion could be anything from getting the mail to reading a book. Nor could the resulting exhaustion be resolved by an afternoon on the couch or a long vacation.

“If they do these activities, they can crash for weeks, even months,” Dr. Moreau said. It was deep, persistent, and – for 40% of those with chronic fatigue syndrome – disabling. In 2015, a study group from the Institute of Medicine proposed renaming chronic fatigue to “systemic exercise intolerance disease” because of the centrality of this symptom. Although that effort mostly stalled, their report did bring the condition out of its historic place as a scientific backwater. What resulted was an uptick in research on chronic fatigue syndrome, which helped define some of the physiological issues that either contribute to or result from the condition.

Researchers had long known about the link between infection and fatigue, said Dr. Frankovich. Work included mysterious outbreaks like the one in Lake Tahoe and well-documented issues like the wave of encephalitis lethargica (a condition that leaves patients in an almost vegetative state) that followed the 1918 H1N1 influenza pandemic.

“As a clinician, when you see someone who comes in with a chronic infection, they’re tired. I think that’s why, in the chronic-fatigue world, people are desperately looking for the infection so we can treat it, and maybe these poor suffering people will feel better,” Dr. Frankovich added. Then the pandemic struck, giving him yet another opportunity to study postviral syndromes.
 

Immunologic symptoms

Given the close link between a nonspecific viral illness and the onset of symptoms in chronic fatigue syndrome, scientists like Dr. Hornig opted to focus on immunologic symptoms. In a 2015 analysis published in Science, Dr. Hornig and colleagues showed that immune problems can be found in the earliest stages of chronic fatigue syndrome, and that they change as the illness progresses. Patients who had been sick for less than 3 years showed significant increases in levels of both pro- and anti-inflammatory cytokines, and the factor most strongly correlated to this inability to regulate cytokine levels was the duration of symptoms, not their severity. A series of other studies also revealed problems with regulation of the immune system, although no one could show what might have set these problems in motion.

Other researchers found signs of mitochondrial dysfunction in those with chronic fatigue syndrome. Because mitochondria make energy for cells, it wasn’t an intellectual stretch to believe that glitches in this process could contribute to fatigue. As early as 1991, scientists had discovered signs of mitochondrial degeneration in muscle biopsies from people with chronic fatigue syndrome. Subsequent studies showed that those affected by chronic fatigue were missing segments of mitochondrial DNA and had significantly reduced levels of mitochondrial activity. Although exercise normally improves mitochondrial functioning, the opposite appears to happen in chronic fatigue.

To Dr. Nath, these dual hypotheses aren’t necessarily mutually exclusive. Some studies have hinted that infection with the common human herpesvirus–6 (HHV-6) can lead to an autoimmune condition in which the body makes antibodies against the mitochondria. Mitochondria also play a key role in the ability of the innate immune system to produce interferon and other proinflammatory cytokines. It might also be that the link between immune and mitochondrial problems is more convoluted than originally thought, or that the two systems are affected independent of one another, Dr. Nath said.

Finding answers, especially those that could lead to potential treatments, wouldn’t be easy, however. In 2016, the NIH launched an in-depth study of a small number of individuals with chronic fatigue, hoping to find clues about what the condition was and how it might be treated.

For scientists like Dr. Nath, the NIH study provided a way to get at the underlying biology of chronic fatigue syndrome. Then the pandemic struck, giving him yet another opportunity to study postviral syndromes.
 

Chronic post-SARS syndrome

In March 2020, retired physician Harvey Moldofsky, MD, began receiving inquiries about a 2011 study he and his colleague, John Patcai, MD, had published in BMC Neurology about something they dubbed “chronic post-SARS syndrome.” The small case-control study, which involved mainly health care workers in Toronto, received little attention when it was first published, but with COVID-19, it was suddenly relevant.

Early clusters of similar cases in Miami made local physicians desperate for Dr. Moldofsky’s expertise. Luckily, he was nearby; he had fled the frigid Canadian winter for the warmth of Sarasota, Fla.

“I had people from various countries around the world writing to me and asking what they should do. And of course I don’t have any answers,” he said. But the study contained one of the world’s only references to the syndrome.

In 2003, a woman arrived in Toronto from Hong Kong. She didn’t know it at the time, but her preairport stay at the Hotel Metropole had infected her with the first SARS (severe acute respiratory syndrome) coronavirus. Her subsequent hospitalization in Toronto sparked a city-wide outbreak of SARS in which 273 people became ill and 44 died. Many of those affected were health care workers, including nurses and respiratory therapists. Although most eventually returned to work, a subset couldn’t. They complained of energy-sapping fatigue, poor sleep, brain fog, and assorted body aches and pains that persisted for more than 18 months. The aches and pains brought them to the attention of Dr. Moldofsky, then director of the Centre for the Study of Pain at the University of Toronto.

His primary interest at the time was fibromyalgia, which caused symptoms similar to those reported by the original SARS long-haulers. Intrigued, Dr. Moldofsky agreed to take a look. Their chest x-rays were clear and the nurses showed no signs of lingering viral infection. Dr. Moldofsky could see that the nurses were ill and suffering, but no lab tests or anything else could identify what was causing their symptoms.

In 2011, Dr. Moldofsky and Dr. Patcai found a strong overlap between chronic SARS, fibromyalgia, and chronic fatigue syndrome when they compared 22 patients with long-term SARS issues with 21 who had fibromyalgia. “Their problems are exactly the same. They have strange symptoms and nobody can figure out what they’re about. And these symptoms are aches and pains, and they have trouble thinking and concentrating,” Dr. Moldofsky said. Reports of COVID-19 long-haulers didn’t surprise Dr. Moldofsky, and he immediately recognized that Nath’s intention to follow these patients could provide insights into both fibromyalgia and chronic fatigue syndrome.

That’s exactly what Dr. Nath is proposing with the two NIH studies. One will focus solely on the neurologic impacts of COVID-19, including stroke, loss of taste and smell, and brain fog. The other will bring patients who have had COVID-19 symptoms for at least 6 months to the NIH Clinical Center for an inpatient stay during which they will undergo detailed physiologic tests.

Scientists around the world are launching their own post–COVID-19 studies. Dr. Moreau’s group in Montreal has laid the groundwork for such an endeavor, and the CoroNerve group in the United Kingdom is monitoring neurologic complications from the coronavirus. Many of them have the same goals as the NIH studies: Leverage the large number of COVID-19 long-haulers to better understand the earliest stages of postviral syndrome.

“At this juncture, after all the reports that we’ve seen so far, I think it’s very unlikely that there will be no relationship whatsoever between COVID-19 and chronic fatigue syndrome,” Dr. Hornig said. “I think there certainly will be some, but again, what’s the scope, what’s the size? And then, of course, even more importantly, if it is happening, what is the mechanism and how is it happening?”

For people like Ms. Gage-Witvliet, the answers can’t come soon enough. For the first time in more than a decade, the full-time professor of epidemiology didn’t prepare to teach this year because she simply can’t. It’s too taxing for her brain to deal with impromptu student questions. Ms. Gage-Witvliet hopes that, by sharing her own experiences with post COVID-19, she can help others.

“In my work, I use data to give a voice to people who don’t have a voice,” she said. “Now, I am one of those people.”

A version of this article first appeared on Medscape.com.