Hepatitis of Unknown Cause in Children Hype or Hazard?

Experts are investigating cases of severe hepatitis of unknown cause in children around the world.

Hepatitis is not rare in children. If fact, we have several vaccines that protect kids from viral hepatitis. What is rather uncommon is to have a prolonged outbreak of severe hepatitis, sometimes leading to liver failure, with no known cause.

Hepatitis of Unknown Cause in Children

And that is what we have been seeing since October 2021, when five children with hepatitis of unknown cause were first identified.

“A possible association between pediatric hepatitis and adenovirus infection is currently under investigation after subsequent laboratory testing identified adenovirus type 41 infection in several cases.”

Clinical Guidance for Adenovirus Testing and Typing of Patients Under Investigation

Since those first cases, at least 180 children with hepatitis have been identified in 36 states.

Cases (at least 276) have also been reported in Austria, Belgium, Cyprus, Denmark, Greece, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Republic of Moldova, Serbia, Spain, Sweden, and the United Kingdom.

“Many cases reported gastrointestinal symptoms including abdominal pain, diarrhoea and vomiting preceding presentation with severe acute hepatitis, and increased levels of liver enzymes (aspartate transaminase (AST) or alanine aminotransaminase (ALT) greater the 500 IU/L) and jaundice. Most cases did not have a fever.”

Multi-Country – Acute, severe hepatitis of unknown origin in children

We also know that:

  • affected children have ranged in age from 1 month to 16 years, with a mean age of two years
  • while most children have recovered, at least 29 children have required a liver transplant, including 15 in the United States (551 pediatric liver transplants were done in the US in 2019…)
  • at least six children have died, include five children in the United States
  • adenovirus has been detected in many of the cases
  • although a current SARS-CoV-2 infection has not been detected in many children, serology for past infection was not in many cases
  • some of the cases had a SARS-CoV-2 and adenovirus co-infection
  • the vast majority of affected children did not receive COVID-19 vaccination

So is adenovirus causing these kids to get sick?

“While adenovirus is currently one hypothesis as the underlying cause, it does not fully explain the severity of the clinical picture. Infection with adenovirus type 41, the implicated adenovirus type, has not previously been linked to such a clinical presentation. Adenoviruses are common pathogens that usually cause self-limited infections.”

Multi-Country – Acute, severe hepatitis of unknown origin in children

While suspicious, since so many of the kids had an adenovirus infection, adenovirus infections don’t usually cause severe hepatitis. And they have not detected adenovirus in the liver of affected children.

That leaves us waiting for the experts to continue doing their investigations.

Your child should be tested for adenovirus if they develop hepatitis.
Your child should be tested for adenovirus if they develop hepatitis.

Can you do anything else to protect your kids from hepatitis?

You can get them vaccinated and protected against known causes of hepatitis, including hepatitis A and hepatitis B.

And while there is no publicly available adenovirus vaccine (there is one available for folks in the military), since one theory is that these cases of severe hepatitis could be caused by a “SARS-CoV-2 superantigen mechanism in an adenovirus-41F-sensitised host,” then getting vaccinated to prevent that SARS-CoV-2 infection could be a good idea.

“One hypothesis suggests the damage is being done by adenovirus, a common childhood infection that normally causes coldlike symptoms and could be treated with an antiviral drug. Another suggests the cause is a rogue immune response to previous infection by SARS-CoV-2—which could be treated with immune-suppressing drugs such as steroids. A third hypothesis proposed earlier this week brings them together, suggesting adenovirus infection forms a destructive partnership with SARS-CoV-2 that sets the immune system loose on the liver.”

What’s sending kids to hospitals with hepatitis—coronavirus, adenovirus, or both?

While it might not protect them from this kind of hepatitis, it certainly wouldn’t hurt and has the added benefit of protecting your child against COVID-19!

Hepatitis of Unknown Cause in Children Hype or Hazard?

While certainly a hazard to the kids who get sick and go on to develop severe hepatitis, this is still fortunately very rare.

“It’s important to note that severe hepatitis in children remains rare. However, we encourage parents and caregivers to be aware of the symptoms of hepatitis – particularly jaundice, which is a yellowing of the skin or eyes – and to contact their child’s healthcare provider with any concern.”

Update on Children with Acute Hepatitis of Unknown Cause

If you are getting worried, keep in mind that worldwide, even as cases are on the rise, only about 500 children have been affected so far and only a small percentage of them have had severe disease.

And most have recovered.

More on Hepatitis of Unknown Cause in Children

The Abbott Recall of Similac, Alimentum, and Elecare Formula of 2022

Check the lot numbers of your powdered Similac, Alimentum and EleCare infant formula and do not feed your baby recalled formula.

Understandably, many parents and their pediatricians are concerned about last week’s infant formula recall.

Abbott voluntarily recalled specific lots of Similac, Alimentum, and EleCare powdered infant formulas over concern that they could be contaminated with Cronobacter sakazakii and Salmonella Newport.

As you are hopefully aware by now, Abbott voluntarily recalled specific lots of Similac, Alimentum, and EleCare powdered infant formulas over concern that they could be contaminated with Cronobacter sakazakii and Salmonella Newport.

The Abbott Recall of Similac, Alimentum, and Elecare Formula of 2022

Do you have any of the recalled infant formula?

Affected formula include specific lots of powdered:

  • Alimentum
  • Alimentum for Toddlers
  • Elecare
  • Elecare Jr
  • Similac Human Milk Fortifier
  • Similac Total Comfort
  • Similac Total Comfort Advance
  • Similac Total Comfort Sensitive
  • Similac Advance
  • Similac Organic
  • Similac Pro Advance
  • Similac Pro Sensitive
  • Similac Pro Total Comfort
  • Similac Sensitive
  • Similac Sensitive Spit Up
  • Similac Spit Up
  • Similac Spit Up Non-GMO

So you may have recalled formula if the multidigit lot number on the bottom of the container (check your lot numbers) of your powdered Similac, Alimentum, or EleCare (all types shown above) that you bought or got as samples includes:

  • 22 through 37 as the first two digits of the code; and 
  • the code on the container contains K8, SH or Z2; and 
  • the expiration date is 4-1-2022 (APR 2022) or later.

If your formula does not contain that information, then it is not included in the recall and you can continue to feed it to your baby.

“If your product is included in the recall, do not use the product and do not dispose of it.  Follow the instructions for return.  If you have questions about feeding your child, contact your healthcare professional.  ”

Abbott Recall General FAQs

The recalled formula was manufactured at one of Abbott’s manufacturing facilities in Sturgis, Michigan, where an onsite FDA inspection found several positive Cronobacter sakazakii results.

An inspection that was triggered by complaints of four infant illnesses (three for Cronobacter and one for Salmonella) from three states – Minnesota (1), Ohio (1), and Texas (2).

“All four cases related to these complaints were hospitalized and Cronobacter may have contributed to a death in one case.”

FDA Investigation of Cronobacter and Salmonella Complaints: Powdered Infant Formula (February 2022)

Did you recently feed your baby any of the recalled formula?

“Cronobacter bacteria can cause severe, life-threatening infections (sepsis) or meningitis (an inflammation of the membranes that protect the brain and spine). Symptoms of sepsis and meningitis may include poor feeding, irritability, temperature changes, jaundice (yellow skin and whites of the eyes), grunting breaths, and abnormal movements. Cronobacter infection may also cause bowel damage and may spread through the blood to other parts of the body.”

FDA Investigation of Cronobacter and Salmonella Complaints: Powdered Infant Formula (February 2022)

While serious, fortunately, Cronobacter infections are rare, especially in older infants. Still, you should seek immediate medical attention if your child has any of the above symptoms.

Many parents, in addition to the fear that their baby might get sick, are facing another big problem – what do they feed their baby if their usual formula is no longer available?

Talk to your pediatric provider, but typically you might consider the following as replacement formulas:

  • A liquid or ready-to-feed version as a substitute for the recalled powdered Similac or Alimentum. Unfortunately, EleCare and Elecare Jr only comes as a powdered formula.
  • Neocate, PurAmino, Alfamino, EquaCare or Essential Care as substitutes for EleCare – might not be perfect match though…
  • Neocate Jr, PurAmino Jr, Alfamino Jr, EquaCare Jr. or Essential Care Jr. as substitutes for EleCare Jr. – might not be perfect match though…
  • Nutramigen, Gerber HA, Pregestamil, or a hypoallergenic store brand as a substitute for Alimentum – might not be perfect match though…
  • Nutramigen for Toddlers as a substitute for Alimentum for Toddlers – might not be perfect match though…
  • Enfamil, Gerber, or a store brand formula as a substitute for standard Similac Advance.
  • A store brand ‘complete comfort’ formula as a substitute for Similac Total Comfort.
  • Enfamil AR or a store brand with added rice starch as a substitute for Similac for Spit-Up.
  • Enfamil Sensitive or a store brand ‘sensitivity’ formula as a substitute for Similac Sensitive, etc.
  • Enfamil Human Milk Fortifier as a substitute for Similac Human Milk Fortifier.

And no, you should not feed your baby recalled formula – not even if you make it with boiled water!

You should also not switch to cow’s milk or goat milk before your infant is 12 months old. Find an alternative formula instead!

Abbott Infant Formula Recall Hype or Hazard

Fortunately, illness from these types of recalls are rare.

Why?

Even with recalls involving possible bacterial contamination, it is mostly premature babies, newborns, and younger infants who are at high risk to get sick. And many of them are either breastfed or get liquid formula until they are older, so aren’t actually exposed.

“Consider using liquid formula when possible. If your baby gets formula, consider using formula sold as a liquid rather than a powder. This is especially important when your baby is less than 3 months old or if your baby was born prematurely or has a weakened immune system. Liquid infant formula is made to be sterile (without germs) and should not transmit Cronobacter infection when handled carefully. Powdered formula is not sterile.”

Cronobacter Infection and Infants

Preparing formula with hot water (at least 158°F/70°C), another thing parents of newborns and younger infants often do, can also lower the risk of getting sick with Cronobacter.

What to Know About the Abbott Infant Formula Recall

Check the lot numbers of your powdered Similac, Alimentum and EleCare infant formula and do not feed your baby recalled formula. Alternatives to these formulas should be available.

More on the Abbott Infant Formula Recall

Going Back to School During the Omicron Surge

How do we get kids back in school safely during the Omicron surge?

How do we get kids back in school and prevent them from getting COVID during the Omicron surge?

“Students benefit from in-person learning, and safely returning to in-person instruction continues to be a priority.”

Guidance for COVID-19 Prevention in K-12 Schools

After all, that’s what everyone wants, right?

Is anyone surprised that Texas leads the US in childhood COVID deaths?
Is anyone surprised that Texas leads the US in childhood COVID deaths?

It’s hard to see how we can do that safely without a lot more people getting vaccinated and boosted, masking, practicing social distancing, more testing, and following through on quarantines for those who are exposed, and isolation for those who are sick.

“CDC recommends universal indoor masking by all* students (ages 2 years and older), staff, teachers, and visitors to K-12 schools, regardless of vaccination status.”

Guidance for COVID-19 Prevention in K-12 Schools

Still, in most cases, folks don’t want to go back to on-line schooling, especially for long periods of time.

So to get kids back in school during the Omicron surge, parents, students, and staff should all work together to keep their kids safe and healthy by:

  • going into home quarantine if they have been exposed to someone with COVID and they are not vaccinated (including a booster dose if they are at least 18 years old and are eligible) or have not had COVID in the past 3 months, remaining in quarantine for at least 5 days. After 5 days, if they have not developed symptoms of COVID, they can get a COVID test and if it is negative, they can return to school, wearing a well-fitting mask for an additional 5 days. And of course, they should get tested if you develop symptoms at any time during these 10 days. If they can’t get tested after 5 days, they can still leave quarantine early if they don’t have symptoms and will wear a mask for another 5 days.
  • going into home isolation if they have COVID, remaining in isolation for at least 5 days, with the ability to end isolation after 5 days if they are fever free for 24 hours, have either had no symptoms or improving symptoms, and will wear a mask for an additional 5 days whenever they are around other people.
  • keeping away from anyone who is at high risk for severe COVID disease until the full 10 days of quarantine or isolation ends.
  • maintaining adequate distance from others during times when they have to take off their mask at school and they are still within the last 5 days of your quarantine or isolation, like when they are eating lunch.

And what if they can’t or won’t wear a mask consistently and correctly and are in quarantine or isolation?

Since they aren't allowed to tell anyone to wear a mask, the Texas Education Agency is trying to implement just half of the CDC guidance to end quarantine and isolation early. Unfortunately, it really doesn't work if you don't wear a mask!
Since they aren’t allowed to tell anyone to wear a mask, the Texas Education Agency is trying to implement just half of the CDC guidance to end quarantine and isolation early. Unfortunately, these plans don’t really work safely if you don’t wear a mask!

Then they should finish out their full 10 day quarantine or isolation at home!

“Staying home when sick with COVID-19 is essential to keep COVID-19 infections out of schools and prevent spread to others.”

Guidance for COVID-19 Prevention in K-12 Schools

What else does the CDC recommend to help keep kids in school safely?

“Vaccination is the leading public health prevention strategy to end the COVID-19 pandemic. A growing body of evidence suggests that people who have completed the primary series (and a booster when eligible) are at substantially reduced risk of severe illness and death from COVID-19 compared with unvaccinated people.”

Guidance for COVID-19 Prevention in K-12 Schools

In addition to vaccination, quarantine and isolation strategies, the CDC recommends consistent and correct mask use, physical distancing, screening testing, improving ventilation, handwashing and respiratory etiquette, contact tracing, and cleaning and disinfection, etc.

“Recommend screening testing for high-risk sports and extracurricular activities at least once per week.”

Guidance for COVID-19 Prevention in K-12 Schools

For example, in areas of low to moderate COVID transmission, doing screening tests of kids in high risk sports and extracurricular activities might help prevent outbreaks. On the other hand, when transmission rates are high, schools should probably just cancel or hold high-risk sports and extracurricular activities virtually to protect in-person learning.

Will this work?

Many big city school districts aren’t convinced and are already delaying the start of the second half of the school year…

“With the above principles in mind, the AAP strongly advocates that all local, state, and federal policy considerations for school COVID-19 plans should start with a goal of keeping students safe, physically present, and emotionally supported in school.“

COVID-19 Guidance for Safe Schools and Promotion of In-Person Learning

Let’s hope the COVID surge ends quickly, states and school districts do more to protect our kids, more people get vaccinated and boosted, and we can get all of our kids back in school!

More on COVID School Guidance

What to Know About Home COVID Tests

They may be hard to get, but at least 16 different home COVID tests are now authorized.

Breaking News – you can now order 4 free at-home tests from the covidtests.gov site. (see below)

Home COVID tests that you can buy over-the-counter have been available for over two years now.

The first home COVID test was authorized by the FDA in December 2020.
The first home COVID test was authorized by the FDA in December 2020.

So why is it so hard to find one when you or your kids are sick and need to get tested?

At Home COVID Tests

Even though there are now many more types of home and OTC rapid COVID tests, it can still be hard to find these tests for one simple reason – high demand during COVID surges.

“The deliveries of tests from manufacturers to the U.S. government will begin over the next week or so. Americans will start receiving free tests in the coming weeks. We will set up a free and easy system, including a new website, to get these tests out to Americans.”

White House COVID-⁠19 Response Coordinator Jeff Zients

Being able to order free tests from the US Government will hopefully help satisfy that demand!

“Every home in the U.S. is eligible to order 4 free at-⁠home COVID-⁠19 tests. The tests are completely free. Orders will usually ship in 7-12 days.”

COVIDtests.gov

That ‘new website’ is now up and running at COVIDtests.gov.

At least 16 different home COVID tests are now authorized.
At least 16 different home COVID tests are now authorized.

Until you order and get your home COVID test from that new website, try and get your hands on whichever home COVID test you can, especially if you don’t have access to testing from your health care provider, a pharmacy, or clinic. After all, they have been all been authorized by the FDA to detect SARS-CoV-2, even if they are not formally FDA approved.

You should also know that:

  • home COVID tests are rapid antigen tests, so are not as accurate/sensitive as molecular or PCR tests
  • if your home COVID test is positive, then you have COVID and you should isolate yourself for at least 10 days (although there are some new options to end isolation early).
  • if your home COVID test is negative, understand that it doesn’t necessarily mean that you don’t have COVID… It really only means that the “the virus that causes COVID-19 was not found in your specimen.” While it may also mean that you don’t have COVID, it could also be a false negative. If you were recently exposed or your symptoms just started, stay in quarantine and test yourself again in a few days. Or consider getting a molecular or PCR test.
  • while most at-home tests are done using a nasal swab, some experts think that with the Omicron variant, doing both an oral swab of the throat and a nasal swab will give more accurate results. That is not how these tests were authorized by the FDA though. Home throat swabbing is also not easy to do by most people. To get the most accurate results, follow the manufacturer’s instructions and maybe don’t test on the first day or two of your symptoms. While you remain in isolation, wait for the viral load to increase in your nose and then test yourself. Of course, seek immediate medical attention if you develop severe symptoms at any point.

Home COVID Collection Kits

In addition to at-home tests, many types of home collection kits are available, in which you collect your sample at home, but then mail it to a lab for testing.

At least 16 different home COVID tests are now authorized.
At least 16 different home COVID tests are now authorized.

In fact, the FDA has authorized at least 63 home collection kits for COVID, including some that can be done on saliva samples!

Unfortunately, these home collection kits are also in short supply…

Fake COVID Testing Kits

Not surprisingly, fake at home tests are also a thing!

Make sure that you buy an FDA authorized at home test, which includes the:

  • BD Veritor At-Home COVID-19 Test by Becton, Dickinson and Company
  • BinaxNow COVID-19 Antigen Self Test by Abbott Diagnostics
  • BinaxNOW COVID-19 Ag Card Home Test by Abbott Diagnostics
  • BinaxNOW COVID-19 Ag Card 2 Home Test by Abbott Diagnostics
  • CareStart COVID-19 Antigen Home Test by Access Bio, Inc (marketed as on/go by Intrivo…)
  • Celltrion DiaTrust COVID-19 Ag Home Test by Celltrion USA, Inc.
  • CLINITEST Rapid COVID-19 Antigen Self-Test by Siemens Healthineers
  • COVID-19 At-Home Test by SD Biosensor, Inc
  • Ellume COVID-19 Home Test by Ellume Limited
  • Flowflex COVID-19 Antigen Home Test by ACON Laboratories, Inc
  • iHealth COVID-19 At-Home Test by iHealth Labs, Inc
  • InteliSwab COVID-19 Rapid Test by OraSure Technologies, Inc.
  • QuickVue At-Home OTC COVID-19 Test by Quidel Corporation
  • QuickVue At-Home COVID-19 Test by Quidel Corporation
  • SCoV-2 Ag Detect Rapid Self-Test by InBios International Inc.

Is your at-home COVID test not on the list?

Check the FDA for the latest list of authorized home COVID tests.

The FDA has sent warning letters to a number of folks marketing fake COVID tests.

And be on the watch for fake at-home tests.

What to Know About Home COVID Tests

For now, while we wait for more at-home tests, if you need to get tested, look for a COVID test wherever you can, whether it is with your healthcare provider, a local pharmacy or community clinic, an at-home test, or a test you collect at home and then send to a lab.

Your local or state health department might also be a good source for community testing and home collection kits.

And if you can’t find a test and think you might have COVID, just stay home in isolation and assume you have COVID.

What else can you do?

Get vaccinated and protected, including a booster dose of the COVID vaccine when it is available to you!

More on COVID Tests

Oral Antiviral COVID Treatments

Paxlovid and Molnupiravir are two new oral antiviral COVID treatments that were recently authorized.

As you are likely aware, a couple of new oral antiviral COVID treatments were recently authorized.

While that’s good news, especially if you have COVID and are at high risk for complications, it is important to understand that these still aren’t a quick cure for COVID.

Oral Antiviral COVID Treatments

So what do these treatments do then?

“Paxlovid consists of nirmatrelvir, which inhibits a SARS-CoV-2 protein to stop the virus from replicating, and ritonavir, which slows down nirmatrelvir’s breakdown to help it remain in the body for a longer period at higher concentrations.”

Coronavirus (COVID-19) Update: FDA Authorizes First Oral Antiviral for Treatment of COVID-19

If you have COVID, taking these medications will hopefully keep you out of the hospital or keep you from dying!

“In this analysis, 1,039 patients had received Paxlovid, and 1,046 patients had received placebo and among these patients, 0.8% who received Paxlovid were hospitalized or died during 28 days of follow-up compared to 6% of the patients who received placebo.”

Coronavirus (COVID-19) Update: FDA Authorizes First Oral Antiviral for Treatment of COVID-19

Paxlovid can be given to adults and children who are at least 12 years old with mild to moderate COVID-19 and who are at high risk of disease progression.

Each dose of Paxlovid consists of 2 pink tablets of nirmatrelvir with 1 white tablet of ritonavir. For each dose, you take all 3 pills at the same time. Paxlovid is given twice a day for 5 days.

Now, although ritonavir is included in Paxlovid to slow down the breakdown of nirmatrelvir, it can also affect other medications you might be taking.

That means Paxlovid is contraindicated if you are already taking any medication that is dependent on CYP3A for clearance or which induces CPY3A, including, but not limited to amiodarone, colchicine, clozapine, lovastatin, sildenafil, trazolam, carbamazepine, phenobarbital, phenytoin, rifamin, and St. John’s Wort. Ask your health care professional and pharmacist if you have any drug interactions before taking Paxlovid.

What about side effects?

In addition to liver problems and drug interactions, possible side effects of Paxlovid include dysgeusia (altered or impaired sense of taste), diarrhea, increased blood pressure, and myalgia (muscle aches).

There are also concerns about extra risks in those with uncontrolled or undiagnosed HIV-1 infection who take Paxlovid.

Where can you get Paxlovid?

As it was just authorized, Paxlovid is in limited supply in most pharmacies and will likely be hard to find.

Your health care professional can prescribe Paxlovid to those who meet the requirements of the EUA. And they have been distributed to many pharmacies, although you may have to call around to get your prescription filled.

Another oral medication, Molnupiravir, was also recently authorized and can be given twice a day for 5 days. Molnupiravir is a nucleoside analogue that inhibits SARS-CoV-2 replication by viral mutagenesis, targeting SARS-CoV-2 RNA-dependent RNA polymerase (RdRp).

“FDA has issued an EUA for the emergency use of the unapproved product molnupiravir for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progressing to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorized by FDA are not accessible or clinically appropriate.”

Frequently Asked Questions on the Emergency Use Authorization for Molnupiravir for Treatment of COVID-19

Unlike Paxlovid, Molnupiravir should only be prescribed when all other alternative COVID-19 treatment options authorized by FDA are not accessible
or clinically appropriate.

“Possible side effects of molnupiravir include diarrhea, nausea, and dizziness. Molnupiravir is not recommended for use during pregnancy because findings from animal reproduction studies showed that molnupiravir may cause fetal harm when administered to pregnant individuals.”

Frequently Asked Questions on the Emergency Use Authorization for Molnupiravir for Treatment of COVID-19

You should not take molnupiravir if you are pregnant or breastfeeding.

“Females of childbearing potential are advised to use a reliable method of contraception correctly and consistently, as applicable, for the duration of treatment and for four days after the last dose of molnupiravir.”

Frequently Asked Questions on the Emergency Use Authorization for Molnupiravir for Treatment of COVID-19

In addition to the warnings about pregnancy, you should not get pregnant while taking Molnupiravir. In fact, although the risk is thought to be low and studies are ongoing, to avoid pregnancy, sexually active males “with partners of childbearing potential are advised to use a reliable method of contraception correctly and consistently during treatment and for at least three months after the last dose of Molnupiravir.”

Your health care provider can prescribe Molnupiravir, but it will likely also be in short supply for a while.

What To Know About Oral Antiviral COVID Treatments

While it is great that we now have even more treatments available when folks get COVID, it is important to understand that these are still unapproved drugs that are authorized for use under Emergency Use Authorization.

More on COVID Treatments

What is Triggering Your Child’s Hives?

Learn how to treat your child’s hives, which could have been triggered by a food, drug, or recent viral infection.

Has your child ever had hives?

What was the first thing you thought of?

If you’re like most parents, it is likely what your child had recently eaten, thinking that is most likely to be what is causing their allergic reaction.

Hives can be scary, because they can appear suddenly all over your child's body. They are one of those things that typically looks worse than it is though.
Hives can be scary, because they can appear suddenly all over your child’s body. They are one of those things that typically looks worse than it is though. Photo by Sussman et al (CC BY 4.0)

It is important to remember that there are many more things in addition to food allergies that can cause hives in kids though. These include medications, infections, exposure to the sun, and for some kids, even physically stroking their skin, which is called dermographism.

What are Hives?

A hive on your child's lip is much different from swelling inside their mouth and throat.
A hive on your child’s lip is much different from swelling inside their mouth and throat. Photo by Sussman et al (CC BY 4.0)

Hives are a type of allergic or immune system reaction that occurs when something triggers the release of chemicals, including histamine, from cells in a child’s body.

Hives are usually harmless if they are the only symptom your child is having.

Unfortunately, children with hives and more severe symptoms, such as wheezing, difficulty breathing or swallowing, or swelling in their mouth or throat, may have anaphylaxis – a life-threatening allergic reaction. These children need immediate medical attention.

Symptoms of Hives

In addition to their typical appearance as red or pink raised areas on your child’s skin, hives are usually:

  • itchy
  • seen alone or are in groups
  • varied in size, with some being smaller than your child’s finger tip and other’s larger than a half-dollar size. Also, hives can often merge or join to form even larger hives that, for example, can cover half of your child’s abdomen.
  • temporary and come and go over several hours. They often don’t go away completely though. Instead, old hives go away in one part of your child’s body, while new ones continue to appear somewhere else. Any individual hive shouldn’t last more than 24 hours. If it does, then your child may have a similar skin rash, such as erythema multiforme, and not simple hives.

Less commonly, hives can sting, be painful, and can leave bruises on your child’s skin.

Kids with hives may have additional symptoms depending on what is triggering the hives. For example, if a viral infection is causing the hives, then they may have a sore throat, runny nose, and/or cough.

What is Triggering Your Child’s Hives?

Although some things, such as certain foods, commonly cause hives, keep in mind that almost anything can trigger hives.

Common causes of hives can include:

  • foods, especially peanuts, eggs, tree nuts, milk, shellfish, wheat, and soy
  • medications, especially antibiotics like penicillin and sulfa drugs
  • additives in foods or medications, such as the food dye tartrazine (Yellow No. 5)
  • infections, especially viral infections
  • insect bites and stings
  • latex
  • exercise
  • stress
  • exposure to heat, cold, or water, no matter what the temperature is
  • dermatographism, a physical urticaria, in which hives are triggered by stroking the skin, such as by scratching

How do you figure out what is causing your child’s hives?

It can be hard.

To help figure it out, keep a diary of all of your child’s medications and everything he recently eat or drank, shortly before breaking out.

Allergy testing is sometimes necessary to figure out what is causing hives, especially if your child’s hives are not going away or they keep getting hives over and over. Fortunately, most kids don’t need testing for their hives, and unless the trigger is obvious, like when it follows eating a peanut butter and jelly sandwich or they are on Amoxil for an ear infection, there is a good chance that they won’t get hives again.

Treatments for Hives

Since hives are caused by the chemical histamine, it makes sense that you would treat them with an antihistamine medication, such as diphenhydramine (Benadryl). Other sedating antihistamines that are sometimes used to treat hives include hydroxyzine (Atarax) and cyproheptadine (Periactin).

Non-sedating antihistamines, including Allegra, Claritin, Clarinex, and Zyrtec, are also used to treat hives, expecially hives that last longer than 6 weeks.

Less commonly, a child may need a steroid to treat his episode of hives.

Other treatments, especially for chronic hives, can sometimes include doxepin (Sinequan), an antidepressant that can work as a potent antihistamine, montelukast (Singulair), and medications such as ranitidine (Zantac) or cimetidine (Tagamet), which are more commonly used to treat reflux.

In some cases of persistent hives, your pediatrician might recommend that you give your child multiple medications, for example, both Zyrtec and Allegra, with Zantac!

Of course, the best treatment for hives, whenever possible, is to remove and then avoid whatever has triggering them.

What You Need To Know About Hives

Hives are not considered chronic or long-term until they last for six weeks or longer. Chronic hives are rarely caused by food allergies. In fact, triggers for chronic allergies are only found about 20 percent of the time.

What if no cause is found for your child’s chronic hives? Then your child has idiopathic hives, which should eventually go away.

What else should you know about your child’s hives?

Individual hives are also called welts (not whelps, a common misspelling for welts) or wheals.

It is a common myth that it has to be something ‘new’ that is causing your child’s hives, as it is much more common that your child has had something two, three or more times before it finally triggers hives.

And although an allergic reaction to a food is usually fairly quick, occurring within minutes to hours, it may take days or weeks for an antibiotic to trigger hives in your child. Your child might not even break out until a few weeks after finishing their last dose!

Also keep in mind that a pediatric allergist and/or pediatric dermatologist can often help your pediatrician figure out what is causing your child’s hives.

More on Your Child’s Hives

The Latest on Masks to Keep Kids From Getting COVID

Face masks work to prevent the transmission of COVID and can help keep kids, many of whom are too young to be vaccinated, from getting COVID.

That kids wearing face masks to keep them from getting COVID is controversial is amazing to many people, especially pediatricians.

Why wouldn’t you want your kids to wear a mask if it could protect them?

The Latest on Masks to Keep Kids From Getting COVID

And yes, the data does show that wearing a mask is safe and protects kids from getting COVID…

Need some proof?

Let’s take a look at what’s happening in Texas.

A few weeks ago, there were 86 active staff and 708 active student cases in GISD.
A few weeks ago, there were 86 active staff and 708 active student cases in GISD.

In one north Texas school district that opened early, on August 2, they now have 67 active staff cases and 564 active student cases.

While that’s a lot, it is important to keep in mind that as cases are continuing to rise in most other school districts, leading to more than a few temporary school closures, they are actually dropping in GISD!

Why?

Staff and students in GISD are wearing masks and their active case counts are dropping!
Staff and students in GISD are wearing masks and their active case counts are dropping! They also limit the capacity for indoor and outdoor events once positivity rates get too high.

It is almost certainly because their staff and students are wearing masks!

Masks Save Lives

Wearing a mask can protect the person wearing the mask and the people around them.

Need more proof that masks work?

Wearing a mask is especially important to protect those who are too young to get vaccinated and those who have a true medical contraindication to getting vaccinated against COVID.

“When used in conjunction with widespread testing, contact tracing, quarantining of anyone that may be infected, hand washing, and physical distancing, face masks are a valuable tool to reduce community transmission.”

An evidence review of face masks against COVID-19

Wearing a mask is also important as COVID variants surge, some of which are more infectious, even to those who are fully vaccinated.

Masks save lives.

“Without interventions in place, the vast majority of susceptible students will become infected through the semester.”

COVID-19 Projections for K12 Schools in Fall 2021: Significant Transmission without Interventions

Parents should ignore the misinformation and disinformation about facemasks and COVID-19.

“To maximize protection from the Delta variant and prevent possibly spreading it to others, fully vaccinated people should wear a mask indoors in public if you are in an area of substantial or high transmission.”

Use Masks to Slow the Spread of COVID-19

In addition to social distancing, they should wear a mask and should encourage their kids who are at least two years old to wear masks in school and when in public around a lot of other people.

More on Masks Save Lives

Treating Kids with COVID Monoclonal Antibodies

While anti-SARS-CoV-2 monoclonal antibodies have an EUA for older, high risk children with COVID, they are not routinely recommended by most experts.

While you are likely used to hearing that there are no real cures or treatments for COVID, a few treatments do have emergency use authorization, including monoclonal antibody therapy.

“Monoclonal antibodies that target the spike protein have been shown to have a clinical benefit in treating SARS-CoV-2 infection. Preliminary data suggest that monoclonal antibodies may play a role in preventing SARS-CoV-2 infection in household contacts of infected patients and during skilled nursing and assisted living facility outbreaks.”

Anti-SARS-CoV-2 Monoclonal Antibodies

And they are available for use in kids who are at least 12 years old!

Treating Kids with COVID Monoclonal Antibodies

So why doesn’t everyone with COVID get treated with these monoclonal antibodies?

“Three anti-SARS-CoV-2 monoclonal antibody products currently have Emergency Use Authorizations (EUAs) from the Food and Drug Administration (FDA) for the treatment of mild to moderate COVID-19 in nonhospitalized patients with laboratory-confirmed SARS-CoV-2 infection who are at high risk for progressing to severe disease and/or hospitalization.”

Anti-SARS-CoV-2 Monoclonal Antibodies

In general, they are mainly used in those older children (at least 12 years of age) and adults who are at high risk for severe disease.

“When using monoclonal antibodies, treatment should be started as soon as possible after the patient receives a positive result on a SARS-CoV-2 antigen or nucleic acid amplification test (NAAT) and within 10 days of symptom onset.”

Anti-SARS-CoV-2 Monoclonal Antibodies

Also, ideally, treatment with monoclonal antibodies should be started very early, but even more importantly, it involves an IV infusion. So it is not something that your pediatrician will likely be able to give your child in their office.

So where can you get these monoclonal antibodies?

“The federal government controls the distribution of monoclonal antibodies, and the regional infusion centers in Austin, El Paso, Fort Worth, San Antonio and The Woodlands have exhausted their supply of sotrovimab, the monoclonal antibody effective against the COVID-19 Omicron variant, due to the national shortage from the federal government. They will not be able to offer it until federal authorities ship additional courses of sotrovimab to Texas in January. People who had appointments scheduled this week will be contacted directly and advised. Other monoclonal antibodies have not shown to be effective against the Omicron variant, which now accounts for more than 90 percent of new cases. The infusion centers will continue to offer those antibodies as prescribed by health care providers for people diagnosed with a non-Omicron case of COVID-19.”

Statement on Monoclonal Antibody Availability

Monoclonal antibody therapeutic treatments have been distributed to hospitals and infusion centers around the country. You can hopefully find a treatment location nearby if you need to get your high risk child treated, keeping in mind that you likely want sotrovimab if you have COVID during the Omicron surge.

How do you know if your child is high risk?

People aged 12 or older may be considered at high risk for developing more serious symptoms—making them eligible for mAb treatment—depending on their health history and how long they’ve had symptoms of COVID-19.
People aged 12 or older may be considered at high risk for developing more serious symptoms—making them eligible for mAb treatment—depending on their health history and how long they’ve had symptoms of COVID-19.

Does your child who is at least 12 years old have chronic kidney disease, diabetes, heart problems, chronic lung disease, including moderate to severe asthma and cystic fibrosis, etc., sickle cell disease, a neurodevelopmental disorder, including cerebral palsy, or have a medical device (tracheostomy, gastrostomy, or positive pressure ventilation, etc.)? Are they immunosuppressed? Are they overweight, with a BMI above the 85th percentile for their age?

Talk to your pediatrician if you aren’t sure if your child is high risk and if you need help finding COVID monoclonal antibodies for your child.

“One dose of Evusheld, administered as two separate consecutive intramuscular injections (one injection per monoclonal antibody, given in immediate succession), may be effective for pre-exposure prevention for six months.”

Coronavirus (COVID-19) Update: FDA Authorizes New Long-Acting Monoclonal Antibodies for Pre-exposure Prevention of COVID-19 in Certain Individuals

Another monoclonal antibody, Evusheld (Tixagevimab Plus Cilgavimab) is available for pre-exposure prophylaxis of adults and children who are at least 12 years old with moderate to severely compromised immune systems due to a medical condition or due to taking immunosuppressive medications or treatments.

Treating Kids with COVID Monoclonal Antibodies?

You may also want to ask if getting your child treated with monoclonal antibodies is something you really should do…

“Currently, there is insufficient evidence for utility, safety, or efficacy to recommend the routine use of monoclonal antibody therapy for children and adolescents with COVID-19, even those considered to be at higher risk of hospitalization or severe disease. At this time, neither bamlanivimab nor casirivimab plus imdevimab should be considered standard of care in any pediatric population, even in patients who meet high-risk criteria. There are no data supporting safety and efficacy in children or adolescents, and the evidence supporting use in the adult population (including young adults) is modest and/or unpublished and has limited applicability to pediatrics or to many specified risk groups.”

Initial Guidance on Use of Monoclonal Antibody Therapy for Treatment of Coronavirus Disease 2019 in Children and Adolescents

And know, that while monoclonal antibody treatments do have EUA for older children, a panel of pediatric experts has recommended against their routine use.

So get your kids vaccinated and boosted now and don’t think you can rely on monoclonal antibodies if they get sick…

More on COVID Treatments

Are We Going to See a Summer Surge of RSV This Year?

Folks need to understand that RSV might still be coming. If not in the next few months, then maybe this summer. And if there is no summer surge of RSV, then it will likely be back even worse next year.

A summer surge of RSV?

I know, it sounds ridiculous, right?

After all, in a typical year, RSV season begins in September or October and peaks in December or January.

Of course, this hasn’t been a typical year…

Are We Going to See a Summer Surge of RSV This Year?

Except for COVID-19, rhinovirus, enterovirus, and some adenovirus, we haven’t seen most of the seasonal viral outbreaks that we typically see each year.

There hasn't been any RSV in Texas this year.
There hasn’t been any RSV in Texas this year.

There was no RSV, flu, or seasonal coronavirus, etc.

Not that anyone has been complaining…

It was one of the bright spots that came out of all of the social distancing, mask wearing, and travel restrictions to control the COVID-19 pandemic!

So why would anyone think that we might see a summer surge of RSV?!?

The news that folks in Australia started getting hit with RSV a few months ago, when it was still summertime!

Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.
Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.

What caused the summer surge of RSV in Australia?

An unexpected surge that is also being reported in South Africa…

“Recent reports from Australia described an inter-seasonal RSV epidemic in Australian children following the reduction of COVID-19–related public health measures from September 2020 to January 2021.”

Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

Is it because they got their COVID-19 cases under good control early and relaxed many of their COVID-19 related public health measures, including eliminating mandates to wear masks and most restrictions on public gathering, and allowed kids to go back to school?

Whatever the reason for the surge, what is most troubling is that we may not have to wait until this summer for our own surge!

“In 2020, the first RSV cases of the 20/21 season were detected in Lyon at week 46 and 47 (Figure 1) at the same time of the southern hemisphere outbreak. A sustained detection of cases was observed from week 51, which is the expected time of the epidemic peak, to week 5. On week 6, the RSV epidemic was declared in the first French region (Ile de France) while the number of RSV cases has continued to increase in the Lyon population.”

Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

France is seeing RSV too – with a 4 month delay to the start of their season. And they haven’t relaxed their physical distancing recommendations as much as Australia, as they were still seeing cases of COVID-19.

And as if all of that wasn’t enough, the summer surge of RSV in Australia is at rates that are much higher than is seen in a typical RSV season!

Wasn’t that expected?

“Our results suggest that a buildup of susceptibility during these control periods may result in large outbreaks in the coming years.”

The impact of COVID-19 nonpharmaceutical interventions on the future dynamics of endemic infections

While larger future outbreaks have been expected, most people likely thought they would start with next year’s season.

“Our findings raise concerns for RSV control in the Northern Hemisphere, where a shortened season was experienced last winter. The eventual reduction of COVID-19–related public health measures may herald a significant rise in RSV. Depending on the timing, the accompanying morbidity and mortality, especially in older adults, may overburden already strained healthcare systems.”

The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures

I’m not sure anyone is ready for RSV and COVID-19 at the same time. That’s not the Twindemic folks were warning us about!

But maybe we should get ready to start seeing some RSV.

March is typically close to the end of RSV season, not the beginning.
March is typically close to the end of RSV season, not the beginning.

After all, rates of RSV are starting to increase in Florida and the South Atlantic division of the United States.

While there is no way to know if we will see this trend in other states and we may just be delaying when RSV season starts anyway, parents should know that we can always protect those who are most at risk from severe RSV disease.

“Ideally, people with cold-like symptoms should not interact with children at high risk for severe RSV disease, including premature infants, children younger than 2 years of age with chronic lung or heart conditions, and children with weakened immune systems.”

RSV Prevention

At some point, we might even have to consider changing when Synagis, the monthly shot that can help prevent RSV, is given. Should we continue giving Synagis to high risk infants this Spring and Summer, for example, instead of stopping in March?

Mostly, folks need to understand that RSV might be coming. If not in the next few months, then maybe this summer. And if not this summer, then it will likely be back with an even worse next year.

More on RSV

What is the Rule of Two/Too?

The Rule of Too/Two is an easy way to discover possible risks of genetic conditions in your family medical history.

Have you ever heard of the Rule of Two?

No, this isn’t about Star Wars…

What is the Rule of Two/Too?

If you didn’t know about the Rule of Two/Too, you will likely be very surprised to know that there are more than one of these rules!

The Rules of Two is a quick and easy way to figure our if your child's asthma is under good control.

The Rules of Two is a quick and easy way to figure our if your child’s asthma is out of control.

Remember that one now?

What about this other one?

The rule of Two/Too.

Arthur Grix proposed the Rule of Too/Two to make things simple for primary care providers when looking for genetic conditions within a family.
Arthur Grix proposed the Rule of Too/Two to make things simple for primary care providers when looking for genetic conditions within a family.

The Rule of Too/Two can help you figure out if you might have a genetic condition in your family!

After all, filling out your family medical history is pretty easy for most people. Knowing what to do with all of that information, especially how it might translate into a risk for a genetic condition is the tricky part…

“Family health history questions that result in answers using the descriptors “too” or “two”may indicate a genetic condition.”

A Toolkit to Improve Care for Pediatric Patients with Genetic Conditions in Primary Care

And that’s where the Rule of Too/Two comes in!

It reviews many of the red flags for genetic conditions and can help you figure out if you or your kids should undergo any kind of genetic screening.

The Rule of Too/Two includes:

  • being TOO tall as compared to their genetic potential for height
  • being TOO short as compared to their genetic potential for height
  • getting sick at TOO early/TOO young an age – extreme early onset cardiovascular disease, cancer, or renal failure, etc., and developing adult disorders in childhood can be a sign of a genetic cause
  • TOO many people in a family having the same condition
  • having an unusual or extreme presentation of a common condition that is TOO different than usual, like breast cancer in a male family member
  • a family member having TWO different types of tumors
  • a condition in TWO generations of family members
  • a condition that affects TWO people in the family
  • a family member with TWO or more birth defects or congenital anomalies

When you fill out your family health history, if you are using the terms ‘too’ and ‘two’ very often, then you might talk to your health care provider to take a closer look.

“Everyone is eligible for one tumor, one birth defect (ASD, cleft lip, birth mark, etc.).”

Arthur Grix, MD

The Rule of Too/Two is an easy way to discover possible risks of genetic conditions in your family medical history.

There are other genetic risk assessment methods besides the Rule of Too/Two.
There are other genetic risk assessment methods besides the Rule of Too/Two.

Which ever method you use, if you find genetic risks in your family tree, you might want to see a genetic counselor for further evaluation.

More on the Rule of Two/Too