As spring turns to summer and Michigan’s COVID-19 vaccination rates climb along with warmer outdoor temperatures, children in the state are resuming their athletic pursuits and preparing for what promises to be a normal school year, complete with in-person learning.

The encouraging expansion of age ranges eligible for vaccination, first to 16 and older, now to 12 and older, offers hope that the pandemic is turning a corner toward being controlled.

However, vaccines from drug makers Pfizer and Moderna are still pending final approval from the FDA and are available under an “emergency use authorization” that expires when COVID spread is no longer considered a public health emergency.

So far, only the Pfizer vaccine has been approved under the emergency use regulations for children 12 and older. Approval for use in children as young as 5 or 6 years old is in the works, and ultimately the vaccines could be made available to children as young as 6 months, said Joseph Fakhoury, MD, FAAP, a pediatric hospitalist with Bronson Pediatric Medicine Hospital Specialists in Kalamazoo.

Rigorous testing ahead of release ensures that the vaccines are safe and effective and final approval is in the works, although it isn’t known for certain when that will happen.

The temporary approval and the speed with which the vaccines were developed has some parents nervous about getting vaccinated and getting shots for their children. But that seems to be the exception rather than the norm.

“Most people have recognized the hopeful nature that follows this vaccine in terms of how do we get back to what we have perceived and labeled as normal before this all happened,” said Fakhoury.

He said so far, children in the 12-plus age group have tolerated the vaccine well, with the same side effects found in vaccinated adults—mostly arm soreness and fatigue within 24 hours of receiving the shot.

Fakhoury said there are some cases being checked for a link between the vaccine and myocarditis. There have not been strong ties proven, but the CDC is reviewing cases.

“What we do know is that COVID can have a much more significant impact on the heart muscle than what we’ve seen the vaccine do,” Fakhoury said. “We should be aware of possible complications, but we should still pursue vaccinations in kids.”

In his Southwest Michigan hospital work as well as across the state and nationally Fakhoury has seen a trend regarding a post-COVID condition that children can get, called multisystem inflammatory syndrome in children (MISC).

“We have actually seen quite the uptick in the last few months than we did last fall, or even last summer. It’s unclear as to why we are seeing it more. A big theory is that last summer and last fall there was a lot more social distancing and staying home and no sporting events and that sort of thing that people adhered to a little bit more than they did early this year, in 2021,” he said.

“That syndrome can be pretty dangerous to kids. It comes down to a lot of inflammation across various different systems in the body, but the one that we worry about the most is the heart. It can cause some changes in the vessels around the heart. It can also cause some damage to the brain and the nervous system, and the lungs as well.”

While the long-term schedules and protocols for COVID vaccines are unclear, Fakhoury said it is safe for children to get COVID vaccines concurrently with their regular childhood vaccine schedule. He said it is important to get both and not to forgo standard vaccinations, a situation that could trigger outbreaks of diseases that have long been under control.

Also up in the air is whether COVID vaccination should be required for school attendance, along the lines of inoculation for other dangerous communicable diseases.

“I don’t think it’s fair to say we should talk about requiring it for schools at this stage of the game. I think we don’t really know how the long-term look for the vaccine is going to be. Is it going to be like the flu shot, where people are going to be encouraged to get it yearly? Are boosters going to be required?” asked Fakhoury.

“We’re really not sure about that yet, so it’s a longer term conversation surrounding schools and requirements. Right now that conversation is with colleges and some colleges are moving in that direction (of requiring vaccination),” he added.

A recent Detroit News feature focused on Albion College requiring COVID vaccinations and Hillsdale College not—although Hillsdale encourages and facilitates vaccinations on campus.

Encouraging vaccination is one thing, providing convenient access to them is quite another. Fakhoury said physicians are working to acquire vaccines they can administer in their offices.

“I think there is always a way to do better at having access to the vaccines. One of the challenges the pediatric community is facing is that we’re still working on getting the vaccine rolled out through pediatric offices that see patients regularly, because right now there is a heavy reliance on health systems and county health departments to reach the pediatric population,” said Fakhoury.

The American Academy of Pediatrics and the Michigan Chapter specifically, are trying to brainstorm and find ways to collaborate with offices and help them become providers that can give the vaccine and enroll in the program.

“There is definitely a push because it is important to have it in the offices because the physician is who the parent trusts most in many cases.”

Physician offices have to let the state know they want to offer vaccines and then enroll as a vaccine provider. Once that process happens, then the state will give vaccine to that office.

“So the push now is better educate offices on how to be a part of that program and then what to do once you are a part of that program,” said Fakhoury.

“This is new for everybody—it’s new for parents, it’s new for kids, it’s new for health care professionals. We obviously know more now than we did a year-and-a-half ago, but we’re all still taking this journey together. So, I would always urge families to never hesitate to talk to their physician and their family docs in terms of any concerns they might have because getting their information from those sorts of folks, rather than just hearing things through the grapevine is much more important and safer for their kids.”

Sometimes children with milder symptoms are missed and these mild symptoms are minimized or ignored in the service of watchful waiting. For older children who seem somewhat socially awkward, younger than their age, or are having frequent “meltdowns,” the following questions may be helpful:

1. Social: Does the child “get” other children or is he frequently left out of play dates? Can they read others’ cues and know when to lay back? Do parents describe circumstances where the child plays alone or alongside/parallel play with other kids but not with them?

2. Sensory: Does the child have significant sensory seeking (water, vestibular/bounding/jumping) or aversive behavior (light, smell, sounds, clothing “too tight” or oral sensitivity)? Does child “observe” things at odd angles or through hands?

3. Routines/repetition: Does child play with things in a repetitive way (lining up/in and out of box)? Does the child have difficulties if his routines are disrupted – causing meltdowns? Rigidity – “my way or the highway” in play or with parents?

4. Speech: If speech isn’t delayed, does child have odd, monotone or “scripted speech” (saying things in the same way or borrowing phrases from TV)?

5. Special interests: Does the child have intense fascination with topics/play materials? Sometimes these are expected (dinosaurs – knows every type/name) and sometimes odd (WW II), and the child might talk about these constantly and is a “little professor” not knowing when they’ve lost their audience. Does the child fixate on devices/screens?

6. Lack of emotional language: Do they have a hard time knowing “how” they are feeling? Can they answer questions such as “What makes you sad”? “How does it feel when you’re sad inside?” “Who are your friends?” “How are friends different from someone you just go to school with?”

7. Lack of creativity or symbolic play: When playing, does the child do things such as crashing characters together, but never really creating a theme?

All of these should be clues to consider specialized testing such as Autism Diagnostic Observation Schedule (ADOS) or referral to a pediatric mental health specialist.

MIAAP is happy to present this monthly column with insights from the MC3 Program’s child and adolescent psychiatrists. MC3 offers no-cost psychiatry support to primary care providers in Michigan who are managing patients with behavioral health problems. To learn more or become an MC3 enrolled provider, visit mc3.depressioncenter.org.

Your efforts to educate families about infant safe sleep are paying off! According to the Pregnancy Risk Assessment Monitoring System (PRAMS), for each of the last four years (2016-2019), Michigan has led all other PRAMS states and territories in the proportion of mothers who sleep their babies in spaces without loose or soft bedding. While this practice has improved over time across all PRAMS sites, the rate of improvement by Michigan mothers has kept pace, allowing us to remain ranked first each year (Figure 1). As you know, keeping baby’s sleep space free of items, including blankets, comforters, toys and pillows, is a key component of infant sleep safety.

The proportion of moms placing their infants to sleep in spaces without toys, pillows, bumpers, or other loose bedding has improved from 51.8% in 2016 to 63.1% in 2019, a gain of 11.3 percentage points. Data pooled among all other PRAMS states, districts, and territories from these same years show that the proportion of moms placing their infants to sleep in spaces without toys, pillows, bumpers, or loose bedding has collectively improved from 41.9% in 2016 to 50.7% in 2019, a gain of 8.8 percentage points.

While there are still improvements to be made, we celebrate the high number of Michigan mothers who choose to sleep their infants without loose or soft bedding. Keep educating families about safe sleep and providing support when needed. Your efforts are making a difference.

PRAMS is a project that gathers high quality, population-based data about maternal attitudes and experiences before, during and after pregnancy. Forty-seven states participate in PRAMS, representing 83% of all live births. Learn more about PRAMS at www.michigan.gov/PRAMS.

Children experiencing foster care may transition between health providers during out-of-home placement. Each transition risks health problems because of gaps in health information transfer.

Transitions to residential treatment pose unique challenges because youth are unlikely to be placed in their home community, residential health teams take over care, and health coverage shifts to Fee for Service Medicaid from Medicaid Health Plans.

On April 1, the Michigan Department of Health and Human Services launched a new Qualified Residential Treatment model for congregate care. This achieves one component of the federal Family First Prevention Services Act of 2018.

The Family First Act drives reforms of each state’s child welfare system by expanding prevention services to promote family functioning, serving children who do come into foster care in family settings, and ensuring that when needed, congregate (QRTP) care is trauma-informed, includes families and caregivers, transitions children back to the community as soon as possible and provides aftercare services for six months.

MDHHS is building on QRTP implementation by improving health information transfer when youth are admitted for residential care through the following steps:

• Child and family workers gather health information from each of the child’s providers.

• Child and family workers collaborate with residential teams to ensure accurate and up to date health information about the child.

• Residential teams work directly with each other when a child transitions between residential programs.

• Residential teams ensure comprehensive, accurate and up to date health information when a child transitions to the community.

Pediatrics offices can support children’s health during transitions by assisting with complete, accurate and timely health information transfer.

The following steps are key:

• Provide health information that child and family workers request in a timely manner.

• Respond to requests from QRTP medical teams for clarification or additional information.

• Participate in planning when children return to the community after residential care.

Regardless of the circumstances, providers who have any questions about a child in foster care with whom they are working should contact the child and family (case) worker. Providers can also get help from the Health Liaison Officer from the child’s county.

Providers can look on the MDHHS Fostering Health Partnerships website for more information about partnering with MDHHS to meet the health needs of children in foster care.

For more information about the Family First Act and Michigan’s actions, see this press release.

Expanded Vaccines

Subtle Autism Signs

Safe Sleep

Health Info Transfer

Stronger Gun Laws

Opportunities Abound

The MIAAP has weathered the COVID-19 pandemic and is stronger and more vibrant than ever. As we fly into the summer months, I am immensely optimistic about the trajectory of the organization and the continued opportunity to increase membership value and expand our programmatic and advocacy footprint.

Membership: Membership continues to grow and we are a few members away from being classified as a “very large chapter.” Our team has a renewed energy to incorporate new pediatrician members, who represent all corners of the state. The MIAAP greatly values diversity and inclusion; we aim to reach potential members across varied professional settings, with hopes of having representation from all 83 counties in the state.

The MIAAP will continue to partner with other health organizations, the State of Michigan and local foundations, to develop relevant program work that will offer educational opportunities to our members. We love to hear from you! If there is a particular program or area of interest that you would like to see addressed and developed, please let us know! We greatly value your input.

Even during the COVID-19 pandemic, the Chapter continued to advocate and lobby for issues members are passionate about; issues that include improved car seat legislation and tighter tobacco/nicotine and vaping laws. The Chapter will continue to listen to our member's concerns and advocate/lobby with integrity and vigor. If you would like a pulse on legislation the chapter is tracking (including MIAAP's position on a particular bill/issue), please take a moment to visit our advocacy website.

Education: FREE Monthly Webinar Series, offering 1 CME per session from June through April 2022, register here.

Programming: If you would like to participate in a comprehensive FREE suicide-prevention training, with an affiliated QI improvement project, offering both 20 CMEs and 25 MOC 4 credits, please contact [email protected]

2021 Annual Conference: September 16th-18th in Grand Rapids. To participate in this year's hybrid Annual Conference, offering 11 CME credits, please register here.