The coronavirus disease 2019 pandemic has presented tremendous challenges to the United States health care system, as well as to individual physicians, communities, and families. Throughout the pandemic, the American Academy of Pediatrics (AAP) has striven to elevate the needs of infants, children, and adolescents, as well as the pediatricians who care for this population. Historically, these communities have often been overlooked and deprioritized in health care systems, and these deficits persisted into the pandemic. To fill this gap, the AAP took on an essential role in leading the national response for pediatrics. This article details the AAP pandemic response and includes the perspectives of multiple AAP leaders involved in the response and details on Academy advocacy with high-level staff and officials at federal agencies and the executive branch. The AAP provided initial guidance to pediatricians that predated the World Health Organization’s declaration of a public health emergency. The Academy then developed entirely new approaches to meet the unprecedented needs of its practicing members and families by providing timely, rigorous information endorsed by pediatric experts. When coronavirus disease 2019 vaccines were developed, the AAP strongly advised the inclusion of those younger than 18 years in vaccine trials and advocated for equitable distribution plans. The AAP provided its members with strategies for combating misinformation. The Academy was at the forefront of advocating for the safe return to in-person schooling, recognizing that social isolation was contributing to the growing mental health crisis among youth. In 2021, the AAP, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in child and adolescent mental health. In addition, the AAP implemented educational and training opportunities for clinicians and developed resources for youth and their families. After the end of the public health emergency, AAP members continue to use innovations and efficiencies developed as part of their pandemic response. The successes of the AAP pandemic response, alongside lessons learned, help define an important model for responding to future pandemics and public health emergencies in ways that support children, families, and the pediatric workforce.

On January 20, 2020, the Centers for Disease Control and Prevention (CDC) reported the first laboratory-confirmed case of coronavirus disease (COVID-19) in the United States, then known as the novel coronavirus. The contagious nature of the virus led to the declaration of a public health emergency by the Secretary of the US Department of Health and Human Services soon after.1 Rapidly evolving worldwide events spurred nationwide and global efforts to understand and treat the newly renamed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pathogen. As scientists worked to collect the limited data available, early reports from the CDC suggested that the prevalence of hospitalization and death were lower among children with COVID-19 than in adults.2 This information provided some relief during a time of great uncertainty; however, it resulted in some attention shifting away from pediatric populations in the United States.

The prioritization of adult populations over infants, children, and adolescents resulted in a void of information for families, pediatricians, and other child-serving professionals. As an organization dedicated to the health of all infants, children, adolescents, and young adults, the American Academy of Pediatrics (AAP) quickly stepped in to fill the urgent need for real-time guidance on pediatric care (AAP staff leadership, oral communication, December 2023). The AAP issued its first guidance for practicing members on February 28, 2020, recommending the implementation of infectious disease protocols in health care settings, calm communication with concerned parents and families, and children’s avoidance of the health care system, unless absolutely necessary, to prevent the spread of infection.3 Illustrative of its faster pace of communication, this guidance from the AAP predated the World Health Organization’s declaration of the COVID-19 pandemic on March 11, 2020.4 The Academy maintained this rapid pace of frequent communication through the pandemic’s speedy evolution, gathering the latest data from authoritative sources, leveraging expert insight, and quickly sharing it even after the public health emergency status was lifted on May 11, 2023.5 

Since its founding in 1930, pediatricians, federal authorities, public health officials, and the public have come to rely on the AAP as an independent trusted source for addressing pediatric health needs.6 Four years after the public health emergency was first declared and 1 year after the emergency was lifted, the AAP is reflecting on its experiences and response during the pandemic to better understand how to adapt this framework to future child health emergencies and pandemics.

This article summarizes the efforts of AAP members and staff who collectively worked toward the mission of optimal child health during the COVID-19 pandemic. This information comes from a comprehensive review of materials documenting Academy response activities from 2020 through 2023, pediatric population data from the CDC, and interviews and surveys of AAP leadership and membership. The AAP used an independent contractor and AAP researchers to conduct panel interviews about the AAP pandemic response and collect written responses from AAP members from November to December 2023. Respondents included AAP leadership, infectious disease experts, vaccine researchers, and child wellness leaders, representative of primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists. The article also contains responses from past leadership of the Academy, collected for a separate AAP project on the COVID-19 pandemic. In addition, the contractor distributed a survey to AAP chapter presidents, vice presidents, and executive directors in November 2023. Many of these respondents provided direct patient care during the peak of the COVID-19 pandemic, between March 2020 and December 2022. AAP researchers and the contractor reviewed and analyzed data from the interviews and surveys, keeping identities of individual respondents anonymous, according to the exempted protocol approved by the AAP International Review Board exemption (AAP IRB protocol number 23 ED 01). These analyses have led to the lessons learned and recommendations contained in this article.

Based on early CDC reports from February to April 2020, the public perceived the COVID-19 pandemic as relatively benign in pediatric populations because of their lower rates of hospitalization and death.2 However, children and adolescents were immediately thrust into a new reality in which the pandemic disrupted every aspect of their lives. About 77% of public schools moved to online learning by the spring of 2020.7 The abrupt transition to online learning meant that families needed computers and a high-quality internet connection so children and adolescents could connect to virtual classrooms (child wellness leaders, oral communication, December 2023). Children from underresourced communities and families who faced significant challenges in accessing remote learning further exacerbated existing educational disparities.8 Children with special health care needs and medically complex conditions especially struggled with remote learning, which limited access to school-based services and educational supports.9 Many children also lost services provided by schools, including meals, clothing, before- and after-school programs, recreation, and health and mental health care (child wellness leaders, oral communication, December 2023).

As children and adolescents shifted to remote learning, fear spread about the potential negative effects on education, development, and social well-being.10 Children lost social connections not only with peers but also with caring adults who acted as positive role models and important advocates for children’s health and safety (child wellness leaders, oral communication, December 2023). Decreases in mandated reporting raised concerns over potentially higher rates of child abuse and neglect.11,13 Furthermore, some children and youth experienced anxiety over the risk of infection and emotional distress from the cancellation of events such as school graduations. As infection rates rose, some children and teens were anxious about the health of their caregivers serving on the front lines of health care while others endured the trauma and grief caused by the death of caregivers from COVID-19.14,15 Still others faced daunting new challenges in the form of financial strain from lost caregiver wages that—at their most extreme—resulted in food and/or housing insecurity.16 

During the first 3 months of the pandemic, COVID-19 was diagnosed in more than 2500 children younger than 18 years.2 Certain populations and communities faced higher rates of hospitalization and death, especially among those identifying as Black, Hispanic or Latino, American Indian, or Alaska Native.17 Patients who survived the infection still faced uncertainty, as COVID-19 complications such as multisystem inflammatory syndrome in children (MIS-C)18 and post-COVID-19 conditions leading to chronic symptoms began to emerge.19 Cases of MIS-C rose in accordance with rising cases of COVID-19, although the first case of MIS-C was reported as early as February 2020.20 Post-COVID-19 conditions in children were first described as early as November 2020.21 

Given that SARS-CoV-2 transmission and infection risk was still incompletely understood, health systems implemented strict measures to mitigate infection risk to health care staff and other patients. However, these measures raised additional emotional challenges for children and families. Children who were hospitalized also faced potential distress when hospital policies limited parental visitation. These mitigation measures were particularly challenging for children with medical complexity, their families, and the pediatricians caring for them.22 

As families struggled with a new reality, so did pediatricians, pediatric medical subspecialists, pediatric surgical specialists, and their practice staff. Lack of data on COVID-19’s effects on pediatric populations impeded pediatric health care, and shortages in personal protective equipment left pediatricians across all settings struggling to manage infection rates and exposure while trying to keep patients, themselves, and families safe (in- and outpatient pediatricians, oral communication, December 2023). Neonatologists and obstetricians were faced with suddenly needing to know how COVID-19 affected pregnant people, neonates, and infants, but had no data to understand the effects of the pathogen on these populations (inpatient pediatricians, oral communication, December 2023). As COVID-19 spread, pediatricians were desperately searching for answers as pediatric deaths began to tick upward (in- and out-patient pediatricians, oral communication, December 2023).

The pediatric workforce was forced to adjust quickly to a new world in which in-person care ground to a halt, some families faced immense struggles, information was limited, and misinformation mounted. Some practices faced massive financial losses and loss of staff while struggling to care for their patients. Many health care staff and other essential workers faced the same health, financial, and social disparities as the families for whom they cared, with adults from Black and Hispanic or Latino populations being disproportionately infected with SARS-CoV-2 and affected by massive social shifts caused by the pandemic response.23 Medical education suffered as online learning increased and hospital administrators reduced patient contact to lessen infection risk (inpatient pediatricians, oral communication, December 2023). As adult infection rates rose, and hospitals became overwhelmed, pediatric hospital staff—including pediatricians but also pediatric subspecialists and pediatric surgical specialists—and resources were reassigned to adult care. The influx of adult patients and low pediatric admission rates resulted in pediatric beds being converted to adult beds in many hospitals (inpatient pediatricians, oral communication, December 2023).24 

At the same time, outpatient practices faced significant financial losses as in-person visits plummeted, but telehealth had not yet ramped up. Health supervision visits decreased, in particular, and families and children missed important preventive health care information and immunizations (outpatient pediatricians, oral communication, December 2023).25 Visits declined as the natural result of families’ isolation and also because of early AAP recommendations to defer in-person, routine well visits, except for newborn infants, to keep children safe. Pediatricians and other medical providers quickly adapted by leveraging telehealth technologies to implement virtual visits as well as innovative solutions to minimize viral transmission, such as closing waiting rooms or holding outdoor clinics to see patients in-person, as needed (AAP staff leadership and outpatient pediatricians, oral communication, December 2023). Pediatricians faced the stress of implementing new workflows, leading their teams through change, balancing personal child and elder care needs, and grappling with the potential risks to themselves and their families. These challenges, combined with the rapid escalation of the severity of COVID-19 in adults, left pediatric clinicians across practices and specialties feeling distressed and unprepared to fight the pandemic.26 

Shortly after the first confirmed SARS-CoV-2 infection in the United States in January 2020, the AAP established an internal COVID-19 Working Group, which used incident command methodologies to manage the AAP response and to support members and staff in rapidly changing times (AAP staff leadership, oral communication, December 2023). The unprecedented circumstances spurred the Academy into rapid action to provide timely guidance to pediatricians and the public during the pandemic. The working group met daily for many months as the pandemic began.

Internally, as AAP staff transitioned suddenly to telework, the organization set up channels for easy and open communication with its membership. Channels included a dedicated COVID-19 e-mail inbox, messaging boards, weekly virtual meetings with AAP Chapter leaders (“Chapter Chats”), and town hall meetings in which members from across the country could converse with experts across many specialties, share the most recent information on a range of topics pertinent to pediatric care, and learn (Fig 1). The AAP also quickly launched a COVID-19-specific Project Extension for Community Healthcare Outcomes (known as Project ECHO) to better serve as a resource for pediatric training and peer-to-peer learning.27 These channels of communication not only served to deliver information to Academy members but also provided crucial avenues of input so that members’ perspectives and experiences could inform AAP activities and areas of focus.

FIGURE 1

AAP COVID-19 response by the numbers.

FIGURE 1

AAP COVID-19 response by the numbers.

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The AAP quickly noticed a gap in publicly available data about COVID-19 cases, hospitalizations, and deaths among pediatric patients. To document the impact of the pandemic on children and fill the gap in pediatric data, the AAP began collaborating with the Children’s Hospital Association to analyze available state data to produce weekly reports on children’s COVID-19 cases, hospitalizations, and deaths, with the first report issued on April 16, 2020.28 The comprehensiveness of the weekly reports were limited by differences in state collection and reporting of data. To track rates of maternal and newborn infection as well as neonatal outcomes, the AAP Section on Neonatal-Perinatal Medicine also launched the National Registry for the Surveillance and Epidemiology of Perinatal COVID-19 in April 2020.29 

Over time, the AAP identified key topic areas where additional guidance would be helpful to its members. The Academy began releasing statements in the form of interim guidance addressing these common concerns (AAP staff leadership, oral communication, December 2023). While maintaining the scientific rigor traditional for AAP policy statements, interim guidance documents went through a more rapid review process that took only a few weeks instead of several years. These documents were updated monthly with new information as knowledge about COVID-19 rapidly evolved (AAP staff leadership, oral communication, December 2023). Over time, interim guidance topics spanned 28 different domains (Table 1),30 with each domain managed by an interdisciplinary team to allow for holistic advice that could be updated as new information became available (AAP staff leadership, oral communication, December 2023). Through this structure, the AAP provided guidance on clinical care, health care delivery, and population and community health30 and provided early, definitive guidance on topics such as safe schools, return to sports and physical activity, and the use of face masks and personal protective equipment, for both pediatric practices31 and for the general public.32,33 

Table 1

AAP Interim Guidance Titles and Initial Release Dates

Clinical Care 
  • FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19 (4/2/2020)

  • Guidance on Providing Pediatric Well-Care During COVID-19 (5/8/2020)

  • Breastfeeding Guidance Post-Hospital Discharge for Mothers or Infants with Suspected or Confirmed SARS-CoV-2 Infection (6/11/2020)

  • Multisystem Inflammatory Syndrome in Children (MIS-C) Interim Guidance (7/13/20)

  • Interim Guidance on Return to Sports (7/22/2020)

  • COVID-19 Testing Guidance (8/12/2020)

  • Caring for Children with Acute Illness in the Ambulatory Setting During the Public Health Emergency (8/25/2020)

  • Caring for Children and Youth with Special Health Care Needs During the COVID-19 Pandemic (9/1/2020)

  • Interim Guidance on Supporting Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic (10/21/2020)

  • Obesity Management and Treatment During COVID-19 (12/7/2020)

  • Supporting Healthy Nutrition and Physical Activity During the COVID-19 Pandemic (12/9/2020)

  • Interim Guidance for COVID-19 Vaccination in Children and Adolescents (2/2/2021)

  • Breastfeeding Guidance Post Hospital Discharge for Mothers or Infants with Suspected or Confirmed SARS-CoV-2 Infection (2/11/2021)

  • Post-COVID-19 Conditions in Children and Adolescents (8/2/2021)

  • Interim Guidance for Use of Palivizumab Prophylaxis to Prevent Hospitalizations from Severe RSV Infection During the Current Atypical Interseasonal RSV Spread (8/10/2021)

  • Outpatient COVID-19 Management Strategies in Children and Adolescents (9/27/2021)

  • Caring for Patients in Inpatient and Outpatient Settings During Episodes of Surge (9/27/2021)

 
Health Care Delivery 
  • Guidance on the Necessary Use of Telehealth During the COVID-19 Pandemic (5/8/2020)

  • Family Presence Policies for Pediatric Inpatient Settings During the COVID-19 Pandemic (7/1/2020)

  • Guidance on Use of Personal Protective Equipment for Pediatric Care in Ambulatory Settings During the SARS-CoV-2 Pandemic (8/12/2020)

  • FAQ’s: Interfacility Transport of the Critically Ill Neonatal or Pediatric Patient with Suspected or Confirmed COVID-19 (8/20/2020)

 
Population/Community Health 
  • Planning Considerations: Return to In-person Education in Schools (5/4/2020)

  • Guidance for Families and Pediatricians on Camp Attendance During the COVID-19 Pandemic (6/10/2020)

  • Guidance on Newborn Screening During COVID-19 (7/16/2020)

  • Guidance for Children and Families Involved with the Child Welfare System During the COVID-19 Pandemic (7/27/2020)

  • COVID-19 and Safe Transportation in Motor Vehicles (8/11/2020)

  • Cloth Face Coverings/Face Masks (8/12/2020)

  • Responding to the Needs of Youth Involved with the Justice System During the COVID-19 Pandemic (8/25/2020)

  • Guidance Related to Child Care During COVID-19 (10/23/2020)

 
Clinical Care 
  • FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19 (4/2/2020)

  • Guidance on Providing Pediatric Well-Care During COVID-19 (5/8/2020)

  • Breastfeeding Guidance Post-Hospital Discharge for Mothers or Infants with Suspected or Confirmed SARS-CoV-2 Infection (6/11/2020)

  • Multisystem Inflammatory Syndrome in Children (MIS-C) Interim Guidance (7/13/20)

  • Interim Guidance on Return to Sports (7/22/2020)

  • COVID-19 Testing Guidance (8/12/2020)

  • Caring for Children with Acute Illness in the Ambulatory Setting During the Public Health Emergency (8/25/2020)

  • Caring for Children and Youth with Special Health Care Needs During the COVID-19 Pandemic (9/1/2020)

  • Interim Guidance on Supporting Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic (10/21/2020)

  • Obesity Management and Treatment During COVID-19 (12/7/2020)

  • Supporting Healthy Nutrition and Physical Activity During the COVID-19 Pandemic (12/9/2020)

  • Interim Guidance for COVID-19 Vaccination in Children and Adolescents (2/2/2021)

  • Breastfeeding Guidance Post Hospital Discharge for Mothers or Infants with Suspected or Confirmed SARS-CoV-2 Infection (2/11/2021)

  • Post-COVID-19 Conditions in Children and Adolescents (8/2/2021)

  • Interim Guidance for Use of Palivizumab Prophylaxis to Prevent Hospitalizations from Severe RSV Infection During the Current Atypical Interseasonal RSV Spread (8/10/2021)

  • Outpatient COVID-19 Management Strategies in Children and Adolescents (9/27/2021)

  • Caring for Patients in Inpatient and Outpatient Settings During Episodes of Surge (9/27/2021)

 
Health Care Delivery 
  • Guidance on the Necessary Use of Telehealth During the COVID-19 Pandemic (5/8/2020)

  • Family Presence Policies for Pediatric Inpatient Settings During the COVID-19 Pandemic (7/1/2020)

  • Guidance on Use of Personal Protective Equipment for Pediatric Care in Ambulatory Settings During the SARS-CoV-2 Pandemic (8/12/2020)

  • FAQ’s: Interfacility Transport of the Critically Ill Neonatal or Pediatric Patient with Suspected or Confirmed COVID-19 (8/20/2020)

 
Population/Community Health 
  • Planning Considerations: Return to In-person Education in Schools (5/4/2020)

  • Guidance for Families and Pediatricians on Camp Attendance During the COVID-19 Pandemic (6/10/2020)

  • Guidance on Newborn Screening During COVID-19 (7/16/2020)

  • Guidance for Children and Families Involved with the Child Welfare System During the COVID-19 Pandemic (7/27/2020)

  • COVID-19 and Safe Transportation in Motor Vehicles (8/11/2020)

  • Cloth Face Coverings/Face Masks (8/12/2020)

  • Responding to the Needs of Youth Involved with the Justice System During the COVID-19 Pandemic (8/25/2020)

  • Guidance Related to Child Care During COVID-19 (10/23/2020)

 

The AAP also advocated to the federal government for financial relief for pediatricians. One clear source of payment and financial support was through the Centers for Medicare and Medicaid Services Provider Relief Fund. Funding became available in “tranches,” with the first tranche including only Medicare providers. Because pediatricians are not typically funded by Medicare, the AAP advocated for and collaborated with Congress to incorporate pediatricians into the pay structure in the second tranche. As a result, Centers for Medicare and Medicaid Services included pediatricians in the Health Resources and Services Administration’s Provider Relief Fund, and $17 billion was distributed to pediatricians who lost revenue and experienced an increase in expenses as a result of the pandemic.34 

Members were critical to the Academy’s COVID-19 response efforts. Pediatrician members produced resources to guide others through issues ranging from the implementation of telehealth to navigating applications for federal funding (outpatient pediatricians, oral communication, December 2023). Pediatric medical subspecialists and surgical specialists also shared information and resources through their respective subspecialty sections, including innovative programs, such as the Pediatric Overflow Planning Contingency Response Network (POPCoRN), which was created by members of the Section on Hospital Medicine to support pediatric hospitalists struggling to adjust to the demands of pivoting to adult care.35 

Members were also crucial in advocacy efforts for pediatric care throughout the pandemic. AAP members testified before Congress (infectious disease and vaccine researchers, oral communication, December 2023) and participated in hundreds of media interviews on topics such as pediatric safety and wellness, how children can return safely to school and child care, and the effects of the pandemic on immunization rates (child wellness leaders, oral communication, December 2023).36 The AAP and member experts connected with pediatricians across the globe to facilitate conversations with academic journals and encourage open access sharing of information (AAP staff leadership, oral communication, December 2023). Although advocacy of AAP staff and its members has always served as a voice for pediatric populations, efforts were magnified during the pandemic and were central to serving children and families and maintaining quality pediatric care throughout the pandemic.

Children Are Deprioritized for Vaccine Development; the Workforce Faces Continuing Struggles

Accelerated efforts in biomedical research fueled by federal funding brought vaccines against COVID-19 to market rapidly, thanks to the fact that mRNA technologies foundational to vaccines were in development long before the pandemic.37 Advances in treatment also occurred at an unprecedented rate. Even so, federal agencies and pharmaceutical companies followed tried-and-true methods of conducting both vaccine and drug clinical trials on adults before pediatric populations for safety reasons. This model, along with the potential influence of the perception that children were not as severely affected by COVID-19, resulted in delays in pediatric vaccinations, with the youngest individuals being last in line to receive protection from vaccines.

Almost immediately after the start of the public health emergency, the AAP advocated for development of pediatric vaccines through letters, joint statements, and testimonies38 to the federal government. The Academy encouraged pediatric and pregnant peoples’ participation in clinical trials. The AAP also recommended distributing vaccines through pediatric practices as opposed to setting up alternative vaccination sites, as a way to minimize vaccine distrust while also ensuring pediatric patients received needed health care. This advocacy continued as the federal government initiated Operation Warp Speed.39 The Academy was 1 of 7 medical groups encouraging this federal effort to follow standard procedures for vaccine approval by the CDC’s Advisory Committee on Immunization Practices,40 which would ensure vaccines were developed based on sound science and, in turn, safe and effective and to strengthen public confidence in vaccines as they became available. “We made it clear what we would and would not accept,” said an AAP expert. “If we don’t believe your data, we won’t support your vaccination. We were not going to rubber stamp anything just to have a vaccination in place” (infectious disease and vaccine researchers, oral communication, December 2023.)

To ensure such high-quality data, AAP members became directly involved in clinical trials, from gathering volunteers for studies to evaluating study endpoints (infectious disease and vaccine researchers, oral communication, December 2023). Despite these efforts and advocacy, as well as the accelerated pace, children were still among the last groups to have an authorized vaccine available, as authorization of pediatric vaccine was dependent on completion of clinical trials. Although the US Food and Drug Administration authorized vaccines from both Moderna and Pfizer for emergency use in individuals 16 years and older in December 2020, children 12 through 15 years of age were not eligible for vaccination until May 2021, children 5 through 11 years of age were not eligible until October 2021, whereas vaccines for infants and children 6 months of age were not available until June 2022 (Fig 2).41 

FIGURE 2

Timeline of key COVID-19 events and AAP actions.

FIGURE 2

Timeline of key COVID-19 events and AAP actions.

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As the US Food and Drug Administration authorized each vaccine in sequence, AAP experts reviewed safety and efficacy data and quickly issued interim guidance or policy recommending COVID-19 vaccination in accordance with CDC recommendations. The AAP also advocated for equitable distribution and access to COVID-19 vaccines and supported members in navigating practice implementation challenges, such as complex storage and handling requirements (infectious disease and vaccine researchers, oral communication, December 2023).42 For example, there were multiple COVID-19 vaccine products with inconsistent recommendations, a rainbow of label colors, and different storage requirements. The AAP created and regularly updated resources, such as the Pediatric COVID-19 Vaccine Dosing Guide, to help pediatric clinicians at the point of care.43 

The delays in vaccine availability for children, the early messaging about the supposed benign effects of COVID-19 on children, and the increasing polarization of the public’s views about public health measures resulted in apathy and even mistrust of pediatric vaccination (infectious disease and vaccine researchers, oral communication, December 2023). From the start of the pandemic, pediatricians and public health officials met significant resistance as they emphasized masking, physical distancing, and other recommended public health measures to reduce the spread of COVID-19.44 The arrival of pediatric vaccines was met by pediatricians with both enthusiasm for improved protection for children against the virus and vaccine hesitancy.45 

Some pediatricians and public health workers faced open hostility over vaccinations from the general public (child wellness leaders and infectious disease and vaccine researchers, oral communication, December 2023). Additional dissent over vaccination emerged within practices themselves. Some office staff refused vaccination, resulting in contentious professional relationships and even terminations of employment (outpatient pediatricians, oral communication, December 2023). These issues emerged as in-person visits continued to increase, adding an additional challenge of catching patients up on missed preventive and chronic care and recommended vaccines, while addressing significant COVID-19 vaccine misinformation (false information caused by getting the facts wrong) and disinformation (false information that is deliberately intended to mislead).

AAP Issues Resources Emphasizing Science-based Information While Countering Misinformation

The AAP recognized pediatricians’ need for support in battling misinformation and disinformation, as many AAP members reported vaccine resistance that was not easily assuaged by their expert guidance as physicians. The Academy leveraged CDC grant funds to support pediatrician vaccine education,46 including information about common parental concerns, techniques for responding to misinformation, and evidence-based recommendations pediatricians could provide.47 The AAP also worked to reach the public directly through social media channels, public service announcements, and its HealthyChildren.org Web site, providing information on the science behind the vaccines48 and the importance of vaccination.49 The social media Call Your Pediatrician campaign also promoted vaccination by encouraging in-person visits to pediatric offices, and introduced new and engaging communication strategies to engage the general public through superhero-themed public service announcements, videos, and social media posts.50 As patients returned to pediatric offices for care, AAP members warned of the escalating toll the pandemic was having on children and adolescents. Children and youth were struggling with isolation, grief, and stress, which was straining their emotional and mental well-being as well as their physical health.

The mental health of children and adolescents had been deteriorating since 2010, so that by 2018 suicide became the leading cause of death for adolescents.51,52 Before the pandemic began, the AAP recognized that school and daily routines were essential to children’s mental well-being. “School is the biggest part of [children’s] lives, so mental health and school are inextricably linked,” said a leader in child wellness (December 2023). Early after the pandemic began, the AAP encouraged safe return to school as soon as possible.53 The AAP promoted a multilayered approach to safety for students and school staff, often called the “Swiss cheese” model of infection prevention, that included strict masking procedures, physical distancing, and improved ventilation, along with implementation of protocols for testing and isolation or quarantine.54 Additionally, the AAP outlined priorities for children with medical complexity who were returning to school.55 

As the pandemic continued, the Academy was quick to recognize the growing toll the disruptions to school and daily routines were having on pediatric mental health. Pediatrician experts in the areas of school health, infectious disease, and developmental or behavioral pediatrics, along with representatives from the National Association of School Nurses, the American Academy of Child and Adolescent Psychiatry (AACAP), teachers’ unions, school administrators, the US Department of Education, the National Education Association, and both federal and community partners, collaborated to refine and regularly update its recommendations for returning to school based on the latest science. This collaboration resulted in holistic guidelines for returning to school that emphasized safety for both children and school staff (AAP staff leadership and child wellness leaders, oral communication, December 2023).

Children were experiencing high levels of stress from the pandemic’s impact on schooling, socialization, and home life. Pediatric populations witnessed both instability and conflict as society grappled with polarizing views over COVID-19 from misinformation and disinformation, systemic inequities, and civil unrest in the wake of repeated episodes of racial violence.56 As stressors to mental health significantly rose, children, adolescents, and families struggled. Despite greater availability of virtual mental health counseling services,57 pediatricians were concerned that the available services would be insufficient to meet pediatric patients’ needs (in- and outpatient pediatricians, oral communication, December 2023).

The AAP continued to form partnerships advocating for pediatric mental health efforts following a report connecting adverse experiences during the pandemic to poorer mental health and rising suicidality among adolescents.58 The AAP worked with the AACAP and Children’s Hospital Association to declare a national emergency in child and adolescent mental health in 2021.52 AAP and AACAP leadership also participated in a virtual media tour to further amplify the declaration. The declaration was initially covered by 33 television news stations, 25 radio stations, and 43 news Web sites and subsequently aired by nearly 260 television and 660 radio news stations. The pediatric mental health crisis declaration prompted further advisory action from the US Surgeon General, calling for immediate action to protect children’s mental health.59 These efforts led to significant growth in federal support for child and adolescent mental health through legislation as part of the American Rescue Plan Act of 2021 (Public Law 117-2). Examples include funding of the Pediatric Mental Health Care Access (PMHCA) program, which allowed PMHCA to expand from 21 to 45 awards in 40 states, the District of Columbia, the US Virgin Islands, the Republic of Palau, the Chickasaw Nation, and the Red Lake Band of the Chippewa Indians, thus providing greater access to mental health screening and pediatric mental health care.60,61 Funding also supported expansion of the Training, Education, Mentoring, and Support model in which the AAP partnered with the National Center for School Mental Health to support improvements in comprehensive school mental health services.

The AAP continues to create and disseminate pediatric mental health resources through its Web site,62 to host Extension for Community Healthcare Outcome sessions on pediatric mental health-related topics, and to work to provide continuous support for PMHCA through its technical assistance program that connects pediatricians with local PMHCA programs.63 There remains much to do even as the immediate challenges of the pandemic have waned. Healthy mental development continues to be a high priority for the AAP (child wellness leaders and in- and outpatient pediatricians, oral communication, December 2023)26 as an essential component of overall health.

There have been 15 594 079 pediatric cases of COVID-19 reported in the United States through May 2023.28 According to CDC data, there have been 109 048 pediatric hospitalizations; and 1785 deaths of infants, children, and adolescents.20 There have also been 5.8 million estimated cases of pediatric long COVID64 and 9655 confirmed cases of MIS-C.20 Currently, 13.5% of children ranging from 6 months to 17 years of age have been vaccinated against COVID-19.65 

The daily lives of children and adolescents have returned to prepandemic routines; however, they continue to experience the effects of academic losses and less social connection during the pandemic. Studies show that the COVID-19 pandemic has negatively affected kindergarten readiness scores.66 Child wellness leaders report a significant drop in high school graduation rates (December 2023). Disruptions to education also include increasing rates of absenteeism in public schools, which have risen from 15% to 30%.67 

Many children will never return to “normal” — as of early 2024, the COVID-19 Orphanhood Calculator estimates approximately 234 500 children lost a primary caregiver, including 218 800 children who lost 1 or both parents.68 Others continue to struggle with lack of access to services for special health care needs.9 Ultimately, the setbacks, isolation, and trauma resulting from the pandemic are likely to leave indelible marks that can affect children throughout their lifetimes. The pandemic’s full impact on child and adolescent development has yet to be fully understood, especially for infants who were born and raised in isolation early in the pandemic. The disparities spotlighted during this time may also increase the lasting impacts of COVID-19 on pediatric populations.69 

Pediatricians and other health care workers have also struggled with mental health and losses sustained during the pandemic. Throughout the pandemic, AAP members bore exponentially heightened professional demands while concurrently facing significant stressors that included staff shortages, frequently changing infection prevention and control recommendations such as masking, and logistical challenges related to supply chain disruption for important clinical care supplies and staff shortages. Many health care workers became sick with COVID-19, and some suffered from long COVID symptoms. Although the AAP and its various committees, sections, and councils provided resources to support colleagues during the pandemic,70 the instability and multiple challenges resulted in poorer care for patients and even greater demands on those remaining in practice (in- and outpatient pediatricians, oral communication, December 2023).

The Academy’s recommendations and advocacy around topics such as COVID-19 vaccines, masking, mental health, return to school, and return to sports and physical activity following COVID-19 illness placed the AAP at the center of many polarized discussions. This trickled down to pediatricians who were implementing AAP recommendations and advocating for children in their respective communities. For some, this resulted in public backlash and open hostility, which added to the pandemic’s emotional toll.29 

Following the pandemic, pediatricians continue to face challenges in hiring adequate staff resulting in heavier burdens placed on the existing workforce. Financial strain, personal losses from the pandemic, and the toll of regularly addressing misinformation and disinformation led to significant physician and staff burnout that continues to stretch the workforce to this day (child wellness leaders and in- and outpatient pediatricians, oral communication, December 2023).26 Many hospitals have yet to restore the pediatric beds converted for adult use during the pandemic. As of 2022, hospitals report that there are 32% fewer pediatric services available compared with 2000 as hospitals eliminated pediatric services or went out of business altogether.71 The financial toll of the pandemic on hospitals and practices has resulted in diminished support for continuing education and board certification preparation (child wellness leaders, oral communication, December 2023). Encompassing these struggles, pediatricians and other medical professionals have continued to face the emotional burden of having their expert training and advocacy for their patients questioned and even vilified.

Still, some challenges that occurred during the pandemic provided opportunities for positive change in pediatrics. The use of outdoor and large-scale vaccination clinics were crucial to increasing vaccination rates.72 Pediatric practices found ways to make in-person health care more efficient as they adjusted to reduce infection risk. Practices changed operating hours, staffing, and how they used waiting rooms. These practices have largely been maintained, and interviewed outpatient pediatricians have favorably reported patients being moved to examination rooms and through appointments at a faster pace (December 2023). Pediatricians and other child health professionals are also using remote platforms to access a wide variety of meetings and educational opportunities with greater efficiency (child wellness leaders, oral communication, December 2023).

Telehealth use exploded during the pandemic, enabling families and patients to remain connected to health care when in-person visits plummeted because of infection concerns. This created new possibilities for health care for both pediatric practices and patients, especially for patients with transportation and access issues (in- and outpatient pediatricians, oral communication, December 2023) and for children with medical complexity.73 Importantly, pediatricians caution that telehealth has the potential to widen disparities just as easily as it can improve them because some populations have less access to internet resources than others. By noting which populations are and are not utilizing telehealth services, practices can ensure all patients’ needs are met by carefully considering how and when telehealth appointments are most effective.

  1. Pediatricians and pediatric health care are underresourced. The COVID-19 pandemic brought to light long-existing disparities and the historic underinvestment in children and those who care for them. “It was important to make sure that [pediatricians] had the resources they need to take care of children during the surge,” said a previous AAP president. “But it was also important not to forget that part of the reason we were in [this] situation is because we’ve been underinvesting in pediatric health care for decades” (previous AAP president, oral communication, August 2023). Pediatricians, pediatric medical subspecialists, and pediatric surgical specialists all faced intensified shortages in resources brought on by both the pandemic itself. The COVID-19 pandemic has additionally highlighted longstanding strain to systems of education and child care. Teachers, school staff, and child care workers have long served essential roles in pediatric health. The value of these services was fully recognized with the pandemic stretching these systems of pediatric care past their limits.

  2. The AAP has a trusted role as a voice for children’s unique needs because of its strong reliance on evidence and scientific expertise. Advocacy throughout the pandemic came from all levels and areas of the AAP, from leadership, staff, and members. Members from all specialties partnered to holistically integrate their expertise, which was critical to the development of AAP information and guidance. A member of AAP leadership said, “People stepped up and stepped forward to help. They offered to be in meetings, in working groups, in writing groups, in the development of new guidance, in evaluating data that was emerging every day” (AAP CEO, oral communication, August 2023). This expertise, collaboration, and communication allowed the Academy to produce and update its guidance rapidly, even in the early days of the pandemic.

  3. The AAP can quickly adapt in an emergency, even in times of uncertainty, to create necessary interim guidance for pediatricians, public health, schools, and families. The AAP quickly adapted to the uncertainty of the pandemic and rapidly generated interim guidance filling the critical need for clinical guidance and evidence-based information on COVID-19’s effects on children and the effectiveness of available countermeasures. The Academy pioneered efforts in pediatric data collection that, combined with expert input, enabled the AAP to issue statements based on authoritative science while allowing for flexibility as new information was acquired. The Academy additionally stepped forward to advocate for pediatric care in multiple areas, including pediatrician support, vaccination, infection control, schooling, child care, mental health, and access to social services. These efforts were bolstered by AAP members and numerous trusted AAP partners from other professional organizations, the federal government, states, and local communities. The Academy will draw on the strengths of its COVID-19 pandemic responses to support the pediatric workforce, specifically by providing clear communication and guidance, informed by continuous learning and assessment of the best data available.

  4. The pandemic took a huge toll on the emotional and mental health and well-being of our children. As the nation moves forward, addressing the pandemic’s toll on child and adolescent mental and emotional health will be one of many challenges for the pediatric workforce. Children and adolescent mental health needs were unmet and climbing long before the pandemic but have been greatly exacerbated by the isolation, losses, and stressors from COVID-19. The AAP has responded. In addition to the mobilization inspired by the declaration of a national emergency in child and adolescent mental health, the AAP has developed a multidisciplinary national Council on Healthy Mental and Emotional Development and implemented a Panel of Mental Health Experts and an Advisory Panel of Parents and Youth to review existing resources and gaps, the latest science, what works, and next steps to oversee all the AAP work in this area.

  5. Equity is a fundamental value to AAP work and must be integral to it all, including addressing and responding to health emergencies. Facing such challenges must integrate consideration of health disparities and inequity, to ensure children from underresourced groups and communities are included in, rather than excluded from, responses and solutions. Marginalization, isolation, and inequity are not acceptable.

  6. The pandemic, combined with the ongoing undervaluation of pediatrics, has negatively affected the well-being of the pediatric workforce itself. At the 2022 Annual Leadership Conference, AAP leadership across chapters, committees, councils, and sections voted on more than 70 resolutions for AAP action. The top priority, Supporting Pediatrician Advocates Experiencing Adversity,74 has resulted in additional advocacy with state and federal courts, Congress, and various media platforms supporting the safety, health, and well-being of the pediatric workforce. The AAP is building on these efforts in its commitment to supporting and protecting the mental health and well-being of the pediatric workforce.75,76 

  7. We are strongest together. In sum, the AAP worked as a whole across leadership, members, and staff to address the considerable challenges of the COVID-19 pandemic. The Academy also established and maintained numerous partnerships with external organizations and the government, at all levels. Child and adolescent safety, health, and well-being; reliance on evidence and scientific expertise; and equity were the fundamental pillars of this work. Essential to this work were AAP members who drove pediatric care through expert input and dedication to their staff, patients, and patients’ families. These collective efforts served as a voice for pediatric populations overlooked by mainstream recovery efforts.

Although the US government declared the end of the COVID-19 public health emergency on May 11, 2023,5 the AAP recognizes there are still needs that must be addressed. Four major areas the Academy is focused on are the ongoing child and adolescent mental health crisis, the academic and social challenges some children are still experiencing, the loss of health insurance and family income as Medicaid and the Child Income Tax Credit phased out, and hardships on pediatric workforce. The AAP continues its work to urge the government to prioritize children’s needs and ensure that AAP members have the support they need to provide high-quality care to their patients.77 

To be prepared for future pandemics, the AAP must leverage the lessons learned during the COVID-19 pandemic and its aftermath to advocate for significant investments in child health and the nation’s child health infrastructure. Child health is a holistic term that includes physical, developmental, emotional, and mental well-being and requires that equity is core to achieving the goal of optimal health for all children. Practically, the COVID-19 pandemic pointed out that the Academy needs to support earlier inclusion of children in clinical trials for vaccines and therapeutics and conduct epidemiologic surveillance of infections in children. Routine childhood immunizations must be increased to avoid disease outbreaks of viruses that continue to make incursions into undervaccinated populations. Pediatric inpatient units that were closed during the pandemic must be reopened so that children in every community have access to high-quality pediatric health care. The AAP must ensure appropriate payment for pediatric services compared with adults, so that pediatric health care remains a viable model. Social factors that are the major threats to child health—poverty, racism, discrimination, and violence—must also be addressed. The pandemic shone a harsh light on the increased suffering endured by marginalized populations who were often on the front lines of care while having less access to that care. Families experienced the benefits of an enhanced Child Tax Credit and expanded Medicaid coverage on lifting children out of poverty, improving nutrition, and promoting family resilience.78,79 

One enduring challenge of the COVID-19 pandemic is a mistrust of public health information and the proliferation of health misinformation and disinformation through various sources—especially those found online and on social media. Clinicians and scientists are accustomed to the evolution of science. However, the rapid pace of that evolution during the early days of the pandemic resulted in public skepticism about practical guidelines with public-facing elements as being insincere or even dishonest because they were updated frequently to reflect new information (AAP staff leadership, oral communication, December 2023). Furthermore, the paucity of information early in the pandemic, variations in the quality of data across states, and the rapidity of communications as the science evolved created a vacuum for those intent on leveraging misinformation and disinformation for personal gain (AAP staff leadership, oral communication, December 2023). AAP leaders and pediatricians from in- and outpatient settings recognized that public mistrust reflected a larger issue in the poor quality of scientific education in the United States (December 2023). These challenges must be considered as the AAP maintains and strengthens its advocacy and support of pediatric populations. The Academy remains committed to serving as an advocate for children and a trusted source of science-based information on children’s health.

Finally, the AAP must continue to expand and strengthen our partnerships at every level. Within and outside of the Academy, partnerships were invaluable to every aspect of the pandemic response. In a future public health emergency, partnerships will again be crucial for gathering data, developing guidelines, and disseminating information and recommendations based on evidence and data. AAP collaborations within its membership and with outside organizations can also be used to continue combating outstanding challenges around science education and misinformation or disinformation.

The AAP is dedicated to continuous evolution of its communications and support of both its membership and staff to inform pediatric care in the wake of the COVID-19 pandemic and prevent pediatric populations from being forgotten in future public health emergencies. Driven by the needs of pediatric populations and their caregivers, the AAP remains resolute in supporting its membership and staff, whose dedication throughout the COVID-19 pandemic was—and continues to be—invaluable to all infants, children, adolescents, and families. Although there are still many challenges left to address after the COVID-19 pandemic, the dedication and contributions of pediatricians, pediatric medical subspecialists, pediatric surgical specialists, and nonphysician clinicians are a source of hope as the Academy moves forward and prepares to face future public health emergencies.

This article is dedicated to the 67 000 pediatricians, pediatric medical subspecialists, and pediatric surgical specialists in the American Academy of Pediatrics who provided care for infants, children, adolescents, young adults, and families during the pandemic. Special thanks goes to the AAP members who contributed in countless, impactful ways to provide education, write guidance, and advocate on behalf of children during this unprecedented crisis. We appreciate all that you do for children and families.

Palladian Partners assisted the AAP with conducting the research and writing the manuscript. Kendall Arslanian, PhD, and Jennifer Monti, PhD, assisted with conducting the research. Sara (Sally) H. Goza, MD, FAAP, Lee Savio Beers, MD, FAAP, and Moira A. Szilagyi, MD, PhD, FAAP, reviewed and provided input on the manuscript.

Mark Del Monte, JD

Anne R. Edwards, MD, FAAP

Debra B. Waldron, MD, MPH, FAAP

Laura D. Aird, MS

Cindy Kennedy Airhart, CAE

Lisa Black Robinson

Dana Bright

Trisha M. Calabrese, MPH

Sean Diederich

Heather Fitzpatrick, MPH

Jennifer Frantz, MPH

Tamar Magarik Haro

Anne Hegland, BS

Kristin Ingstrup

Melissa Jenco, MA

Sunnah Kim, MS, RN

Susan Stevens Martin, APR

Devin Mazziotti

Monique Phillips

Jamie Poslosky

Jeremiah Salmon

Mary Claire Walsh

Mary Lou White

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