Trends – A Back-To-School Season Like No Other

‘Don’t rush things,’ advise pediatric and education experts

During an American Academy of Pediatrics-sponsored virtual “town hall” meeting this spring, Susannah Briskin, M.D., FAAP, member of the AAP Council on Sports Medicine and Fitness Executive Committee, spoke about the potential of stress fractures among young people returning to athletics following a long period of relative inactivity due to the pandemic. A colleague, Carol Cohen Weitzman, M.D., FAAP, immediate past chair of the AAP Section on the Developmental and Behavioral Pediatrics Executive Committee, picked up on the comment and added a cautionary note about “metaphorical” stress fractures. She was referring to challenges that returning students might face due to the emotional, academic and intellectual stresses experienced during the pandemic.

Welcome to back-to-school, the post-COVID-19 version.

Flu disappeared …
but what’s next?

This year’s back-to-school season should be unlike any other. For one thing, influenza and respiratory syncytial virus (RSV) all but disappeared this past winter, raising questions about what might happen this fall. Many epidemiologists believe the flu’s absence was due to precautions put in place to stem the pandemic, though others speculate that the coronavirus simply crowded out all other viruses. The bottom line is, the Centers for Disease Control and Prevention reported just one influenza-associated pediatric death during the 2020-2021 season. (The death occurred in February 2021.) In contrast, the total number of pediatric deaths occurring during the prior flu season – 2019-2020 – was 196.

Some experts are predicting a strong resurgence in respiratory viruses this fall, as precautionary measures, such as mask-wearing and physical distancing, are lifted. Others believe that immune systems might have been weakened without exposure to the flu virus during the 2020-2021 season, opening the possibility for flu to roar back with a vengeance.

“I don’t have any way to predict whether this will happen or not, but we can be sure that other respiratory viruses will continue to circulate in some fashion as they always have,” says Bonnie Maldonado, MD, FAAP, chairperson of the American Academy of Pediatrics’ Committee on Infectious Diseases, and Professor, Departments of Pediatrics and Health Research and Policy at Stanford University School of Medicine.

As of this June, the nation was experiencing a surge in RSV, which was unusual given that the virus tends to appear in late fall and winter, she says. “It is possible that RSV will taper off before its normal fall season. Also, based on what is happening in the Southern Hemisphere, flu is not at high numbers, and their seasons are usually – but not always – similar to what we see during our winter months, which occur about six months later.”

Impact of delayed care

Pediatricians are concerned about the potential impact of delays in childhood visits and vaccinations during the pandemic. “We are concerned that children are not up to date on a number of vaccines and may be at risk for transmission of vaccine-preventable diseases,” says Maldonado. As of June, the U.S. was behind on childhood vaccinations by over 11 million doses since the first surge of the pandemic in March 2020. “Families should be sure to get their children up to date on all of their regular vaccines and get them vaccinated against COVID-19 if they are 12 and older.”

Some children experienced immediate adverse effects from COVID-19 this past year, including multisystem inflammatory syndrome in children (MIS-C), which causes inflammation of different body parts, including the heart, lungs, kidney, brain, skin, eyes or gastrointestinal organs. CDC reports that many children with MIS-C had the virus that causes COVID-19 or had been around someone with COVID-19. Though MIS-C can be deadly, most children who were diagnosed with this condition have gotten better with medical care.

Other kids may be facing longer-term effects from the coronavirus. For example, obesity prevalence increased in children and adolescents from pre-pandemic levels, according to the American Academy of Pediatrics in a May 2021 report. Many risk factors that result in weight gain were present in the pandemic, including disrupted family routines, sleep dysregulation, reduced physical activity, increased screen time, increased access to unhealthy snacks, and less access to appropriately portioned meals through school breakfast and lunch. Closures of recreational sports, gyms, and schools resulted in less access to opportunities for organized physical activities.

Return to pre-pandemic levels of activity should be gradual, advised Briskin, who in addition to her AAP activities practices pediatric sports medicine at University Hospitals in Cleveland. “We’ve seen a lot of inactivity. Kids have been at home doing virtual schooling, and a lot of sports have been put on hold, then they decide to try out for a sport like track, and get an overuse injury, such as a stress fracture.

“Everyone is eager for normalcy, but I encourage kids to start moving again by just starting with walking consistently to get some basic level of conditioning. We recommend making sure that kids have well-fitted supportive athletic shoes to start. If they have been inactive for more than a month, they should start at no more than 25% of their usual exercise volume and do impact exercise no more than three times a week. A gradual increase in 10% of volume per week can help prevent overuse injuries. Activities such as core exercises, light resistance training, stretching, and low-impact activity can ramp up more quickly.”


Pediatricians and others express concern about the mental/psychosocial health of kids during and after the pandemic due to isolation, economic and emotional pressures at home, inactivity, and challenges associated with learning for kids with special needs.

In late May 2021, Jena Hausmann, CEO of Children’s Hospital Colorado, drew attention to the matter by declaring a “State of Emergency” in youth mental health. “[W]e are seeing our pediatric emergency departments and inpatient units overrun with kids attempting suicide and suffering from other forms of major mental health illness,” she said. “The reality is that health challenges facing kids have gone beyond crisis levels, and the organizations that serve kids are overwhelmed. Many children, families, local schools, county governments and healthcare facilities are at their breaking points.”

It’s a worldwide problem.

In March, researchers in Ireland reported that “the disruption to educational, social and recreational activities removed children from peer networks and social interaction, which may cultivate social isolation. The disruption of schools and community services – often a safety net for children – may further leave children vulnerable, particularly those at heightened risk of neglect. Furthermore, children with pre-existing behavioral conditions, such as autism, and those who rely on specialist- or community-delivered health services, may be disproportionally affected by not having their needs met.”

“[Pandemic-related health issues in children] will play out over a long time as these children struggle to catch up and manifest the consequences of COVID,” Camilla Kingdon, MBChB, consultant neonatologist at Guy’s and St Thomas’ NHS Foundation Trust in London, England, was quoted as saying in May. “The next few years are going to be equally challenging for both children and the professionals who work with them.”

Kids in adverse circumstances

Sensitive and caring adults can help children manage stress, but kids who experienced (or continue to experience) food insecurity, housing insecurity, and tension and violence in the home may suffer.

The pandemic led to the closure of many businesses and lost wages for countless workers, noted the National Institute for Children’s Health Quality (NICHQ). And because of school closures, many parents had to take unpaid time off work to care for their kids. Lacking regular income, families may have been forced to make life-altering decisions, like choosing between buying groceries, paying the rent, or getting gas so they could bring their child to a doctor.

“Even before COVID-19, millions of children lived in households that struggled to put food on the table, and now the pandemic has only deepened that crisis, especially for Black, Latino, and Native American families,” said Luis Guardia, president of the Food Research & Action Center in January.

Many known risk factors for child abuse and violence – including poverty, stress, and isolation – were exacerbated by the pandemic, said the AAP in a COVID-19 guidance document. Loss of contact with teachers and physicians may make their detection by healthcare providers more difficult.

LGBTQ youth living in homes where they are not supported by their families may have experienced greater stress during the pandemic, according to AAP. “These youth may be subjected to increased physical or emotional maltreatment from a family member and not have a means to escape it.” Furthermore, they may have been isolated from support systems, such as the local LGBTQ center or their LGBTQ friends/community.

Academic pressures

A return to in-person schooling after a year of remote learning may present challenges for children from an academic point of view, said Dr. Weitzman at the AAP virtual town hall, who in addition to her duties with the Academy is co-director of the Autism Spectrum Center at Boston Children’s Hospital and a member of the Division of Developmental Medicine. “Bringing kids back to school and thinking they are ready for the next level of curriculum without modification will cause ‘stress fractures,’ metaphorically speaking.”

She urged kids to attend summer programs when they are available to facilitate a gradual re-entry into in-person schooling, and for schools and communities to recognize the urgent need to promote smooth re-entry and catch-up.

Writing in “eSchool News” in April, Chris Minnich, CEO of NWEA, said, “If we expect back-to-school to be normal, then we missed the mark. (NWEA is a nonprofit organization that develops Pre-K-12 assessments and professional learning offerings.)

“Nothing about the past year was typical,” he said. “Each student was impacted by the pandemic differently, so our approach to recovery must be as unique as them. And it can’t just be about catching kids up by cramming more into the following year or holding them back. We must focus on the critical areas of unfinished learning while also attending to the mental well-being of our kids, many of whom completely disconnected from their teachers and peers for an entire year and may just now be returning.”

Pediatrician’s role

The pandemic underscored the need for pediatricians to integrate emotional and behavioral health as part of standard care, noted the AAP in its guidance document. “The role of the pediatrician may include surveillance of high-risk families, vigilance and recognition of signs of abuse, and inquiring about intimate partner violence, guns in the home, parental mental health and well-being, self-care, and struggles with child and adolescent behavior and discipline.”

Danielle Dooley, M.D., member of the AAP Council on School Health and medical director at the Child Health Advocacy Institute at Children’s National Hospital, says COVID-19 has highlighted the need for schools, community organizations and health systems to work together to holistically address children’s needs.

“Pediatricians and their staff can identify opportunities in their community to engage in these partnerships, ranging from formal, ongoing collaboration to more sporadic, one-time events,” she says. For example, pediatricians can serve on a school board as a school physician or sports team physician, or as a consulting physician for a school district. They can also offer their expertise or that of a staff member, such as a nurse, health educator or social worker, to present information for a parent and family town hall sponsored by a school or community organization.

“In some instances, pediatric practices develop formal partnerships with a school or organization to conduct sports physicals, for example, so that children can benefit from the positive experiences associated with team sports,” she says.

“Pediatricians can start by finding out what organizations or resources their patients and families use and then reach out to them to offer their expertise and also learn how that organization is serving children and families and how the pediatric practice can support or refer.”

Sentinels of student health

Teachers and school nurses will be on the front lines when students return to school this fall.

“School nurses are the sentinels for student health,” says Laurie Combe, MN, RN, NCSN, president of the National Association of School Nurses. “When students lack the language to express their emotions, or they perceive stigma from doing so, those emotions often present as physical complaints. That means the nurse might be the very first person to see the indicators a child has emotional health concerns.

“This year, we’re looking at children who may have experienced loss of parents or other close relatives and friends to COVID,” she says. “Child abuse reporting is way down because schools are often the first to recognize signs of abuse. Children may have been exposed to more violence, either personally or through something they witnessed.

“And they’ve missed significant events, such as graduation from Pre-K, grade school, high school; or family events, even funerals. On top of that, we know some families have struggled economically because of the pandemic. Housing and food may be insecure, and that may never have been the case for them before this.”

School nurses, in conjunction with counselors and teachers, have learned a lot about how to deliver virtual health services during the pandemic, says Combe. “They have been working with students on emotional management, teaching them how to relax, and who they can reach out to for help.

“When student symptoms indicate an urgent need for medical intervention, school nurses refer those students to community mental health providers. They have continued to support students with chronic health conditions and their families, making sure they understand how to provide day-to-day care, which is particularly important for students with new diagnoses.

“Still, it’s not the same as being able to come into the school clinic or counselor’s office, or staying behind in class to talk with a trusted educator about what’s really going on.”

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