Celeste Krewson

COVID-19 can cause severe infection in neonates in rare instances, according to a recent study.

About 3% of COVID-19 cases in the United States have been in pediatric patients aged 0 to 4 years, making rates significantly lower in this population. This has been attributed to inherent protective factors present in young children.

In instances of neonatal COVID-19, symptoms are often mild, with a good overall prognosis. However, newer variants have become highly transmissible, causing cases to rise in neonates.

To study the outcomes of neonatal COVID-19, investigators conducted a cross-sectional study across the United States on the incidence, geographic distribution, severity, features of presentation, and clinical outcomes.

Data was gathered from the Cerner Real-World Database, which contains data from over 120 United States health systems. Neonates aged under 28 days diagnosed with COVID-19 between March 1, 2020, and February 28, 2021, were included in the study.

Outcomes measured included incidence of COVID-19 infection, incidence of severe illness, geographic distribution of infection, and treatment received. Severeness was classified as any case that contained symptoms from 2 of 3 categories. In the first category, symptoms included: fever greater than 37.5 degrees Celsius, apnea, cough, tachypnea, respiratory distress or recession, supplemental oxygen requirement, and vomiting or diarrhea.

In the second category, symptoms included: any of low white blood cell count, low lymphocyte count, and raised C-reactive protein concentration. The third category was measured by abnormal chest x-ray.

Of 1,007,269 encounters, 918 were identified as positive for COVID-19. About 8% of these cases were measured as severe COVID-19. A greater proportion of severe cases were seen in male patients compared to female patients. The median age at admission to hospital was 11 days for regular cases and 15 days for severe cases.

As only 209 patients had mode of delivery recorded, investigators hypothesized that COVID-19 incidence occurred most often in neonates subsequently after delivery. Low birth weight in neonates was more likely to lead to severe COVID-19 than non-severe COVID-19. About 47% of severe cases were comorbidity.

Neonates were often asymptomatic at birth. Tachypnea and fever were the most common initial symptoms, and about 28% of infants with severe infection were observed with pneumonia.

Results indicated low chance of severe COVID-19 and death in neonates, but not 0 chance. Investigators recommended further research on how congenital abnormalities affect COVID-19.

This article originally appeared on Contemporary Pediatrics®.

Devin J, Marano R, Mikhael M, Feaster W, Sanger T, Ehwerhemuepha L. Epidemiology of neonatal COVID-19 in the United States. 

 2022;150(4). doi:10.1542/peds.2022-056297

Articles

In a recent study, severe COVID-19 made up 8% of cases among neonates aged less than 28 days.

Severe COVID-19 rare in infants

Jenny Madrid, MPH, RD, CDCES, BC-ADM, diabetes care and education specialist, gave a presentation on nutrition therapy used to treat gestational diabetes at the Nurse Practitioners in Women’s Health (NPWH) 25th Annual Premier Women's Healthcare Conference in Houston, Texas, from September 29 to October 2.

In the presentation, Madrid discussed the key components of Medical Nutrition Therapy (MNT) for Gestational Diabetes Mellitus (GDM). In cases of diabetes in pregnancy, Madrid mentioned how women will have to change their lifestyle behavior for proper management, developing a plan with a health care provider for MNT.

Diets should be a minimum of 175 g of carbohydrates, 71 g of protein, and 28 g of fiber. Nutrient dense carbohydrates were the most vital part of the diet mentioned, as they control glucose, reduce free fatty acids and excess infant adiposity, improve insulin action, and can provide vascular benefits.

When designing an MNT plan, Madrid recommended focus on carbohydrate intake, quality of carbohydrates, nutrient dense carbohydrates, nutrition needed for pregnancy, and level of saturated fat consumed. Plans should suit the individual and be culturally appropriate.

As insulin resistance is part of pregnancy and increases over time, total insulin doses should as well. The increase should be linear and 5% a week for 36 weeks. Cases will vary between individual women, with some women modifying their diets while others rely on insulin, which is the primary way to treat diabetes during pregnancy.

Though GDM is common, Madrid noted how it can be confusing, scary, and anxiety producing, along with how changes in diets can be difficult with cases of nausea, vomiting, heartburn, and food cravings. There may also be challenges in food insecurity and ability to cook, along with cultural norms surrounding pregnancy. These are just some of the barriers which can prevent optimization of MNT.

To reach the appropriate level of carbs, Madrid recommended steps such as limiting consumption of sugar beverages, carb counting, analyzing food labels, and reviewing and addressing barriers. For nutrient dense carbs, Madrid suggested grains, oats, beans, vegetables, fruit, and dairy products.

Saturated fat increases insulin resistance, leading Madrid to push for healthy fats which are provided by seeds, nuts, avocados, olive oil, and sesame oil. When measuring grams, 30 grams for breakfast, 60 for lunch, and 60 for dinner is best.

Madrid encouraged attendees not to make nutrition harder than in needs to be, reminding them that no diet is perfect. Each MNT should be individualized, and even with a strong MNT, some women will still need insulin. Proper expectations should be set by both healthcare providers and patients.

In a diet, Madrid found that carbs should not be low, nor should fat be high saturated. According to Madrid, tools should be customized for target populations.

Madrid J. Nutrition therapy for the treatment of gestational diabetes. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.

In a recent presentation the NPWH 25th Annual Premier Women's Healthcare Conference, Jenny Madrid, MPH, RD, CDCES, BC-ADM, discussed medical nutrition therapy, a type of treatment plan for managing gestational diabetes by adjusting to an appropriate diet.

How changes in diet can manage gestational diabetes

Carri Holton, MSN, WHNP-BC, Department of Pediatric & Adolescent Gynecology at Children’s Hospital Colorado, gave a presentation on gynecologic care for adolescent patients at the NPWH 25th Annual Premier Women's Healthcare Conference in Houston, Texas, from September 29 to October 2.

Holton first outlined how health care providers can provide preventive health screenings and offer guidance to adolescents, teens, and parents in pediatric gynecology. Conditions such as pediatric vulvovaginitis, lichen sclerosis, genital injuries, labial adhesions, congenital anomalies in the reproductive system, menstrual suppression, tumors, premenstrual syndrome and premenstrual dysphoric disorder, and breast problems in youths are treated via pediatric gynecology, as is fertility preservation or hormone replacement.

During an office evaluation, there should be a welcoming environment for adolescent patients, according to Holton. Health care providers will require technical skills to complete hymen exams, single-digit exams, and smaller speculums. They will also need to have the patience to listen to adolescents and parents, along with learning the history of their patients.

Confidentiality was also discussed. Holton noted that adolescents must be made aware of instances when information is not confidential, such as suicidal or homicidal thoughts. Minor consent laws should be known, as many states allow minors to consent to family planning, pregnancy care, substance use related care, and outpatient mental health services. All states allow minors to consent to sexually transmitted infection testing.

When arranging and performing an adolescent exam, the decision should be between the adolescent and the provider, though there should be a chaperone present. Providers should explain all components of the exam to the patient and parent. Patients should be reassured that they are in control of their body and the exam can be stopped at any time.

When moving onto the next step, providers should ask permission to pull the sheet back. Holton reminded them to be explaining female anatomy with proper terms, educating parents and patients. Breasts and pubic hair should be examined for Tanner staging, and external genitalia should be examined for normal anatomy.

In the presentation, Holton discussed normal pubertal development along with abnormalities, and encouraged attendees to learn this information so that they may recognize signs of abnormal development. Providers need to first identify the cause then determine treatment. This could include hormone replacement therapy in cases of primary ovarian insufficiency.

Holton also outlined instances of physiologic anovulation—when slow maturation occurs in anovulatory cycles. This can lead to noncyclic, unpredictable, and inconsistent bleeding. In cases where bleeding is too much, adolescents should see an oncologist for testing, especially in cases of concerning history with bleeding disorders in the individual or family.

In cases of mild bleeding without anemia, providers should reassure patients, provide them with prophylactic iron supplementation, and offer hormonal contraceptives if desired. In moderate bleeding with anemia, providers should give patients combined oral contraceptives, micronized oral progesterone, depo Provera injection, levonorgestrel (LNg) intrauterine device (IUD), and iron supplementation.

Further treatments, along with hospitalization and blood transfusion, may be needed in cases of severe bleeding. In all cases, Holton stated that iron supplementation should be given.

Holton also discussed polycystic ovary syndrome (PCOS), reminding attendees that every case is different. Holton also noted that PCOS is not caused by ovarian cysts or being overweight, and that much is still unknown about PCOS. Diagnoses may be given as “irregular periods,” and can present as amenorrhea, oligomenorrhea, and chaotic periods.

Treatment for PCOS will vary based on concerns, as it can lead to metabolic concerns, acne, dermatologic concerns, and nutrition concerns. When these concerns arise, screenings should establish a rapport in the first visit. Repeated screenings should at first take place every 3 months, then every 3 to 12 months depending on the patient.

Holton lastly talked about dysmenorrhea and endometriosis. Dysmenorrhea is painful menstruation, often increasing risk of anxiety and depression. It can be managed with dietary, vitamin, and herbal treatments along with exercise and yoga, or with pharmacologic interventions.

Dysmenorrhea is often caused by endometriosis. Risk factors of endometriosis include earlier menarche, nulliparity, shorter menstrual cycles, childhood sexual and physical abuse, and more. To treat endometriosis, Holton recommended both surgical and medical treatments. Complementary and alternative therapies may also reduce symptoms.

Holton C. Gynecologic care for the adolescent patient: perspective from a PAG WHNP. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.

In a recent presentation at at the Nurse Practitioners in Women’s Health (NPWH) 25th Annual Conference, Carri Holton, MSN, WHNP, discussed gynecological complications that adolescents may face and offered practical treatment options.

Caring for the gynecologic needs of the adolescent patient

Katie Huffling, DNP, RN, CNM, FAAN, executive director at Alliance of Nurses for Healthy Environments, recently gave a presentation on how environmental exposures have impacted women’s health at the 25th Annual Premier Women's Healthcare Conference in Houston, Texas, held in-person from September 29 to October 2.

In her presentation, Huffling examined data from the World Health Organization, stating that up to 24% of global diseases are caused by environmental exposures, which could be avoided with proper protocols. This makes up a part of the 80% of major diseases significantly impacted by the environment. In children, environmental exposures are the source of 33% of diseases.

Over 280 industrial chemicals were found in newborns during a benchmark investigation, stated Huffling.These chemicals included 217 brain/nervous system toxicants, 180 carcinogens, and 208 birth defects or abnormal development. When exposed to these chemicals, individuals may develop asthma, lung disease, autism, attention-deficit/hyperactivity disorder, Parkinson’s, autoimmune disorders, cancer, obesity, and complications in reproductive health such as fertility and breast cancer.

These chemicals can also be found in some personal care products. Huffling provided data stating that only 11% of chemicals in cosmetics have been screened for safety. Flame retardants also contain chemicals which can increase the risk of cancer, endocrine disruptors, and neurological impacts.

To minimize risk, Huffling suggested methods of reducing exposure to these kinds of pollutants. These include keeping flame retardants from children, using a vacuum with a HEPA filter, mopping floors and dusting furniture regularly, washing hands frequently, thoroughly cleaning a car’s interior, and using naturally flame-resistant fabrics.

There are also risks of exposure to harmful chemicals in certain types of food. Huffling listed a “dirty dozen” food products with these risks, which consisted of strawberries, spinach, kale, nectarines, apples, grapes, peaches, cherries, pears, tomatoes, celery, potatoes, and hot pepper.

To counter risk, Huffling also listed a “clean 15.” These products are safe for consumption, and included: sweet corn, avocadoes, pineapples, papaya, onions, frozen sweet peas, eggplant, cauliflower, cantaloupe, broccoli, mushroom, cabbage, honeydew melon, kiwi, and asparagus.

Huffling also reminded attendees to avoid water contaminated with per- and polyfluoroalkyl substances. This can help reduce exposure, along with avoiding microwave popcorn, decreasing processed food consumption, and using cast-iron pans over Teflon nonstick pans.

Phthalates were also discussed, as they can lead to metabolic issues, elevated blood pressure, precocious puberty, fertility issues, pregnancy complications such as low birth weight and preterm birth, neurodevelopment, and respiratory impacts.

To reduce exposure, Huffling recommended avoiding plastic wrap and plastic food containers, keeping plastic out of the microwave, avoiding products with fragrance or phthalate on the label, reducing fast food consumption, and supporting policies for banning phthalates.

For increased safety in women preparing to have children, Huffling suggested the Safe Baby Products Guide. This allows women to research information on specific baby products and understand how the chemicals in certain products would affect their baby’s health. Huffling reminded women that baby products can be affordable when you separate what you need from what you don’t need.

Climate change was also a concern, as a rise in temperature and changes in natural events such as drought, flooding, and forest fire affect women’s health. Many of the health impacts mentioned previously are also brought about by the effects of climate change.

The health impacts of climate change include adverse pregnancy outcomes, increased risk of certain conditions in young children with greater biological sensitivity, and increased risk of exposure to heart-related illnesses in activities of older children.

Huffling stressed the impact advocacy can make, especially among health care providers’ voices. This can be at an association and institutional level, a community level, or a state and federal level. Huffling concluded the presentation by showcasing the fracking ban in Maryland, a case where health voices made a difference.

Huffling K. Impact of environmental exposures on women’s health. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.

In a presentation at the Nurse Practitioners in Women’s Health (NPWH) 25th Annual Conference, Katie Huffling DNP, RN, CNM, FAAN, explained how different cases of environmental exposure are impacting women’s health. 

How environmental exposures affect women’s health

COVID-19 vaccination has been associated with an increase in menstrual cycle length of less than 1 day, based on a large international study.

The study, which was funded by the National Institutes of Health and published in the 

, gathered data from almost 20,000 people across the world who had received any of the 9 different COVID-19 vaccinations. In most participants, menstrual cycle length saw an increase after the vaccine was administered.

“These findings provide additional information for counseling women on what to expect after vaccination,” said Diana Bianchi, MD, director of National Institute of Child Health and Human Development. “Changes following vaccination appear to be small, within the normal range of variation, and temporary.”

This change in cycle is under 8 days, making it fit within the normal range of variation. While not concerning from a professional standpoint, the study authors noted that even minor changes in bodily function surrounding fertility may cause concern and increase vaccine hesitancy.

Data was gathered from a fertility tracking app called Natural Cycles, where women voluntarily provided information on menstrual cycles and body temperature. Over 19,000 individuals participated, with almost 15,000 being vaccinated against COVID-19 while over 4500 were not.

Over 30% of participants were from the United Kingdom, while about 30% were from the United States and Canada, and almost 35% from Europe. Participants were included if they had received any of the following vaccinations: Pfizer-BioNTech, Moderna, AstraZeneca, Covishield, Janssen/Johnson & Johnson, Sputnik, Covaxin, Sinopharm, and Sinovac.

The study period lasted at least 4 consecutive cycles, with at least 3 before vaccination and at least 1 after vaccination being studied. In the cycle after vaccination, vaccinated individuals experienced an average increase of less than 1 day, increasing by about 70% of a day after the first dose and about 55% after the second dose.

Over 1300 participants experienced an increase in cycle length greater than 8 days, making up 6.2% of those vaccinated and 5% of those unvaccinated. This increase was mostly likely in younger woman who had experienced longer circle length prior to vaccination.

The authors recommended further studies to observe other potential physical changes, along with the reasons these changes occur.

Study confirms link between COVID-19 vaccination and temporary increase in menstrual cycle length. National Institutes of Health. September 27, 2022. Accessed September 27, 2022. 

https://www.nih.gov/news-events/news-releases/study-confirms-link-between-covid-19-vaccination-temporary-increase-menstrual-cycle-length

In a recent study, participants who had received a COVID-19 vaccine saw an average increase in menstrual cycle length of less than 1 day.

COVID-19 vaccine associated with increased menstrual cycle length

State child abuse policies and mandated reporting policies reduce visits by pregnant people to prenatal care and postpartum health care, according to a recent study.

Analyzing the United States’ overdose crisis, investigators have observed concerns over substance use during pregnancy. In the 2020 National Survey on Drug Use and Health, 8% of pregnant people reported recent illicit drug use. There has also been a significant increase in opioidand amphetamine affected births in the past few years.

Associations have been made between substance use during pregnancy and adverse outcomes during birth, such as low birth weight, preterm birth, and severe maternal morbidity and mortality. Policies addressing prenatal substance use have arisen in some states, including policies that label substance use during pregnancy as child abuse. Certain policies require that healthcare professionals report instances of prenatal substance use to child welfare agencies.

Child abuse policies have been implemented in 23 states and the District of Columbia, while mandated reporting policies have been implemented in 26 states and the District of Columbia. Leading medical and public health organizations have spoken against child abuse policies, expressing concerns that they will lead less pregnant people to be open to prenatal care and substance use disorder (SUD) treatment in fear of punishment.

Prior studies have indicated reluctance of pregnant people who engage in substance use to seek prenatal and postpartum care out of fear of legal consequences. As early and consistent prenatal care leads to healthy outcomes, investigators stressed the importance of pregnant people visiting care centers, especially in cases of SUD.

Investigators conducted a cross-sectional survey, taking data from the Pregnancy Risk Assessment Monitoring System from 2016 to 2019. This data consisted of a sample of women who delivered a live birth during that year, divided into subgroups based on maternal race and ethnicity and infant birth weight.

A survey was given to women 2 to 6 months postpartum through mail or telephone, with questions about prenatal substance use and health care visits. Over 4000 women were surveyed across 23 states, and the years in which states had child abuse or mandatory reporting policies were noted.

Prenatal care was recorded based on timing and adequacy, while postpartum care was recorded based on a self-reported receipt by women. Less than 1% of data were missing a receipt for a postpartum healthcare visit.

About 34% of women delivered in states with only a child abuse policy, about 16% in states with a mandatory reporting policy, about 33% in states with both, and about 17% in states with neither. Adequate prenatal care was most seen in states with both policies at 75.1%, then states with neither policy at 75%. States with only child abuse policies saw a 64.1% prenatal care rate, and those with only mandatory reporting policies saw a 66.4% prenatal care rate.

Women on average sought prenatal care about a month later in states with one or more policy compared to states with neither. States with one or more policy implemented saw a decrease in women’s likelihood to receive adequate prenatal care. Postpartum care visits were also less likely in these states. Women in these states were 8.7% to 12.4% less likely to visit postpartum care 4 to 6 weeks after delivery than those in states who had neither policy.

These results indicate that child abuse and mandatory reporting policies decrease the likelihood of women receiving prenatal and postpartum care. This supports statements by leading health and medical organizations that these policies may deter pregnant people from seeking care.

Austin AE, Naumann RB, Simmons E. Association of state child abuse policies and mandated reporting policies with prenatal and postpartum care among women who engaged in substance use during pregnancy. 

 2022. doi:10.1001/jamapediatrics.2022.3396

Investigators found that women in states with child abuse or mandated reporting policies were less likely to visit prenatal care and postpartum health care.