Advances in Pediatrics 70 (2023) xxi–xxiii

ADVANCES IN PEDIATRICS

PREFACE

Is It Over Yet? Did I Miss Anything?

Carol D. Berkowitz, MD

S
ince the start of the COVID-19 pandemic, I have focused this preface on
the changes that occurred over the previous year and how the pandemic
affected our lives and medical care. Each year since 2020, Advances in Pe-
diatrics has highlighted articles dealing with the impact of COVID-19 on certain
areas of life or medical care. Sometimes the effect was positive, as described by
Humphrey and colleagues in their article, ‘‘Pediatric Disasters: Evolution of a
Hybrid Health Training Program during the COVID-19 Pandemic.’’ The use
of virtual technology expanded the ability to teach about the management of
pediatric disasters. Of note, this methodology allows for the participation of
multinational faculty and asynchronous learning, and even as the pandemic
wanes, this more global approach to learning through virtual sessions will most
likely persist. On a more somber note, Flynn-O’Brien and Georgeades report
that the incidence of violent injuries in children increased during the initial
phase of Stay-At-Home. Many injuries involved firearms and disproportionally
impacted socially disadvantaged children. While attributing such injuries to the
pandemic is still an area under investigation, understanding other areas of child
maltreatment continues to be refined. Distinguishing between accidental and in-
flicted burns involves obtaining a complete history, including the child’s devel-
opmental progress. As with other areas of child maltreatment investigations,
there needs to be involvement of a multidisciplinary team, often including so-
cial work and law enforcement. A multidisciplinary team is equally integral to
the evaluation of what has come to be called Medical Child Abuse, also called
Munchhausen Syndrome by Proxy. In these cases, a child’s alleged symptoms
may be fabricated or actually induced. Often the symptoms don’t fit into a
classic diagnostic pattern, and physicians feel obligated to search for a cause,
thus subjecting children to multiple, invasive, and unnecessary tests. Often
the parent goes to multiple different medical facilities ‘‘searching for an
answer.’’ While the list of alleged symptoms is lengthy, neurologic complaints,
including seizures, apnea, and altered mental status, are high on the list.
True neurologic conditions in children may also be challenging to both diag-
nose and manage. Myasthenia gravis in infants and children is a rare neuro-
muscular disease that may be on a genetic basis, especially if congenital.
Misdiagnosis or delayed diagnosis can occur when an infant presents with

https://doi.org/10.1016/j.yapd.2023.04.007
0065-3101/23/ª 2023 Published by Elsevier Inc.
xxii PREFACE

atypical features. On the other hand, Guillain-Barre syndrome, though rare in

children under the age of 2 years, affects both children and adults and is the
most common cause of flaccid paralysis. The diagnosis of Guillain-Barre is
based on history and physical findings, but laboratory and electrophysiologic
studies provide supportive evidence.
While much elective surgery was curtailed during the pandemic, emergent
surgery persisted with the evolution of some new approaches. The accuracy
of the diagnosis of appendicitis has been augmented by ultrasonography and
involvement of the family in shared decision making of operative or nonoper-
ative management. The surgical management of thyroid disease in children oc-
curs in three situations: nodular thyroid disease, Grave disease, and multiple
endocrine neoplasia (MEN). Children with MEN 2 develop abnormalities of
the thyroid, parathyroid, and adrenal glands based on the specific mutations
of the RET photo-oncogenes, and the evaluation of the specific mutation deter-
mines the risk for medullary thyroid cancer as well as pheochromocytoma and
hyperthyroidism. Likewise, certain genetic conditions are associated with CA-
KUT (Congenital Anomalies of the Kidney and Urinary Tract). While there
are multiple genes that have been associated with CAKUT, there are specific
genes seen with LUTO (Lower Urinary Tract Obstruction), for example,
Prune Belly Syndrome (CHRM3-autosomal recessive; Filamin A- X-linked).
Prenatal diagnosis and genetic testing can help delineate a management plan.
Impressive advances in the management of a number of medical conditions
have also appeared in the forefront of pediatric care. We are all aware of the
incredible advances made in the management of acute leukemia in childhood.
Chronic myeloid leukemia (CML) is significantly less common, accounting for
only 2% of leukemia in childhood and 9% of leukemia in adolescence. CML
results form a translocation t(9-22). In brief, this translocation generates
messenger RNA, resulting in constitutive kinase activity providing leukemic
cells with a growth advantage. Tyrosine kinase inhibitors target this activity
and have proven to be revolutionary treatment for CML. Equally revolution-
ary has been the augmented therapies for the management of atopic dermatitis.
These modalities target immune modulators (eg, Th2 pathway), which are up-
regulated in atopic dermatitis. These treatments have led to improvement not
only in the skin but also in the quality of life.
Two other conditions are discussed in this issue of Advances in Pediatrics. Sud-
den Cardiac Death is an ever-present concern for the physician assessing a
youngster for chest pain, palpitations, and syncope. While most chest pain is
noncardiac, the physician is challenged with the extent of the workup and
when to refer the patient to a cardiologist. Equally challenging is the care of
transgender and gender-diverse children. It is critical for all pediatric health
care providers to gain the knowledge and the skills of gender development,
to understand the spectrum of gender-affirming care, and to be prepared to
address the disinformation that has appeared, including on social media.
My title for this preface is ‘‘Is it over yet? What did I miss?’’ It is hard to tell if the
COVID-19 pandemic is officially over. Many jurisdictions have declared the
PREFACE xxiii

COVID-19 emergency over, which impacts on a multitude of things, personal,

societal, and medical. My sense is that things will continue to slowly normalize,
and hopefully we can retain what has improved things, like the increase in phone
visits and virtual meetings and conferences. I can’t help but be reminded of the
1925 poem, ‘‘The Hollow Men’’ by T.S. Eliot: ‘‘This is the way the world ends,
Not with a bang but a whimper.’’ One morning COVID-19 won’t be on the
forefront.
My next query is ‘‘What did I miss?’’ Hopefully not much. Early on in the
pandemic, it seemed the entirety of medical reports dealt with COVID-19—
epidemiology, prevention, complications, treatment. That has also changed,
but Advances in Pediatrics, even throughout the pandemic, kept its readership
apprised not only on COVID-19–related issues but also on the continued prog-
ress being made across the board in pediatric medicine. My answer to ‘‘What
did I miss?’’—not much!

Carol D. Berkowitz, MD
Division of General Pediatrics
Department of Pediatrics
Harbor-University of California Los Angeles Medical Center
David Geffen School of Medicine at UCLA
1000 West Carson Street
Box 437
Torrance, CA 90509, USA

E-mail address: cberkowitz52@gmail.com