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Commentary From the Section on Uniformed Services

September 19, 2023
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Commentary From the Section on Uniformed Services

The American Academy of Pediatrics (AAP) Section on Uniformed Services (SOUS) was established in April 1959. The SOUS provides education, resources, and policy guidance related to the care of military children and offers career support and mentorship for health care professionals who care for military-connected families. The current strategic priorities of the SOUS are to consult with the AAP Department of Federal Affairs on issues important to military-connected children and their providers; to address the mental health of SOUS members; and to expand the presence and impact of junior members within the SOUS.

An informal task force composed of senior military pediatricians and the SOUS Section Manager, Ms. Jackie Burke, identified an initial list of potential articles for this project. The team then met to narrow down and prioritize the selections to honor the breadth and depth of contributions to Pediatrics from the uniformed services throughout the past 75 years.

Disclaimer: The views expressed in these commentaries are those of the author(s) and do not reflect the official policy of the Uniformed Services University of the Health Sciences, the United States Air Force, the Department of the Army, the Department of the Navy, the Department of Defense, HJF, or the US Government. This work was prepared by military employees of the US Government as part of those individuals’ official duties. All content in this document, to include any publication provided through digital link, is considered unclassified, for unrestricted open access without copyright protection.

Landmark Papers Published in Pediatrics by Members of the Section on Uniformed Services

First Quarter Century: 1948 – October 1973

Agammaglobulinemia: The First Description of a Pediatric Immunodeficiency Condition

Michael Rajnik, MD, FAAP, FIDSA, FPIDS

Affiliation: Department of Pediatrics, Uniformed Services University

Highlighted Article From Pediatrics

In 1952, Dr. Ogden C. Bruton, often considered the father of military pediatrics, published a article in Pediatrics entitled “Agammaglobulinemia” that described the past 4-year medical history of an 8-year-old boy at Walter Reed Army Hospital who suffered from repeated episodes of pneumococcal sepsis and who failed to show antibody responses to available vaccines (diphtheria toxoid and typhoid vaccine). He noted that sulfadiazine antimicrobial prophylaxis was unsuccessful and that the boy did not generate immunoglobulin responses to pneumococcal serotypes that had been isolated from his blood or to antigenic polysaccharides. Additionally, he had been twice diagnosed with “epidemic parotitis,” now known as mumps, but did not show complement fixing antibodies nearly 1 month after infection.

Dr. Bruton connected the clinical presentation of this child to children with severe nephrosis or malnutrition who had been found to have low levels of gamma globulin. He used the relatively new technology of electrophoresis to demonstrate that the child had a complete absence of gamma globulin. Based on this observation, Dr. Bruton administered subcutaneous immune serum immune globulin and documented a decrease in gamma globulin levels from a peak post-injection to undetectable by 6 weeks after the injection. During 14 months of serial injections, the child did not develop any serious infections. This supported Dr. Bruton’s hypothesis that hypogammaglobinemia was the cause of the child’s immunodeficiency.

In a 1998 commentary,1 Dr. Rebecca Buckley hailed “Agammaglobulinemia” to be a seminal article because it was the first report of a human host defect as the etiology of recurrent infections. Previously, repeated infections were attributed to repeated exposures or changes in the pathogen leading to issues for the patient. This disease pattern of a child who was clinically healthy for the first few months of life due to the transfer of maternal antibodies but later developed serial infections due to the lack of ability to make gamma globulin became known as Bruton’s Agammaglobulinemia. As genetic mechanisms began to be refined, it was later determined that this defect could be found on the X chromosome at Xq22.2 The defective gene product was a tyrosine kinase essential for normal human lymphocyte signaling.3 This tyrosine kinase also bears his name and is known as Bruton tyrosine kinase (Btk).

Due to this observation and scientific discovery, Dr. Buckley considered Dr. Ogden C. Bruton, of the United States Army, to be the father of the field of study of human primary immunodeficiencies. The AAP SOUS recognizes these accomplishments with the Ogden C. Bruton Award that lauds the best paper submitted by a military pediatrician for either basic or applied research on the development, evaluation, or application of technology in pediatrics. Additionally, the Ogden C. Bruton Lectureship recognizes a uniformed pediatrician as a distinguished lecturer at the AAP National Conference and Exhibition.

References

  1. Buckley RH. Agammaglobulinemia, by Col. Ogden C. Bruton, MC, USA, Pediatrics, 1952;9:722–728. Pediatrics. 1998;102(Suppl 1):213-215
  2. Vetrie D, Vorechovsky I, Sideras P, et al. The gene involved in X-linked agammaglobulinaemia is a member of the src family of protein-tyrosine kinases. Nature. 1993;361(6409):226-233
  3. Tsukada S, Saffran DC, Rawlings DJ, et al. Deficient expression of a B cell cytoplasmic tyrosine kinase in human X-linked agammaglobulinemia. Cell. 1993;72(2):279-290

ABOUT OGDEN C. BRUTON
Ogden C. Bruton (14 June 1908 – 20 January 2003), born Mt Gilead, N.C., graduated from Duke University in 1929 and Vanderbilt University School of Medicine in 1933. He completed pediatric training at Vanderbilt in 1936, remaining there as faculty. He joined the US Army as a reserve officer in 1940 and served on active duty during WWII. He was assigned to Walter Reed Army Hospital in 1946, where he founded a pediatric residency program and directed the program until his retirement after over 20 years of Army service. A seminal event in Bruton’s career was his care for an 8-year-old boy, son of an Air Force general officer, in whom he ultimately diagnosed agammaglobulinemia. Bruton published a report on this patient in Pediatrics in June 1952. Time Magazine reported his discovery on May 18, 1953.

In 1948, the Army sent Dr. Bruton to Europe to assess the quality of pediatric services being provided to military families stationed there. He visited a small Army clinic in Linz, Austria, and met an “impressive young pediatrician named Angelo diGeorge,” predicting a fine future for Dr. DiGeorge. Dr. DiGeorge, a famous Philadelphia endocrinologist, reported the case of immunodeficiency in a baby found not to have a thymus, a syndrome later named for him. I once met with Dr. DiGeorge and he remembered Dr. Bruton’s visit and smiled at the serendipity. 

Val Hemming, MD
Col, USAF, MC (Ret.)


The Legacy of Leo Geppert in the Epidemiology of Pediatric Practice and Pediatric Diseases

Patrick W. Hickey, MD, FAAP, FIDSA

Affiliation: Department of Pediatrics, Uniformed Services University

Highlighted Article From Pediatrics

“Composition of Pediatric Practice at a Permanent Army Base in the Antibiotic Era,” published in Pediatrics in 1958 by Colonel Leo J. Geppert, is a keystone article that provides one of the best epidemiological analyses of pediatric morbidity and mortality in the mid-20th century. It also highlights the unique role that military pediatricians serve in caring for the children of service members stationed around the globe. At that time, Colonel Geppert was the chief of pediatrics at Walter Reed Army Medical Center in Washington, DC, and had recently completed a tour of duty as the theater consultant for pediatrics in the Far East. In that capacity, he oversaw the care of children in military families across the Pacific theater of operations who had supported the global security demands placed by the Second World War, Korean War, and subsequent Cold War. This article described the epidemiology of illnesses among the pediatric patients at Brooke Army Hospital in San Antonio, TX; the Tokyo General Dispensary; and Walter Reed Army Hospital in Washington, DC, over 10 years. Utilizing the Standard Nomenclature of Disease, a precursor to today’s International Classification of Diseases, Dr. Geppert systematically detailed the incidence rates per 100,000 children under 10 years of age per year for every condition evaluated. Dr. Geppert notes that this was the first comprehensive epidemiological analysis of pediatric disease rates in the era of antibiotics.

Much of the workload Dr. Geppert describes would be familiar to pediatricians today: routine well-child care comprised more than half of total visits before the age of 10, and in a precursor of telemedicine, the typical child had “an average of 30 telephone calls…completed per child.” The high rates of what would become vaccine preventable illnesses, such as measles, polio, mumps, and rubella, are reminders of the fragile progress that has been made in protecting the well-being of children. Writing before the advent of modern neonatology in the 1960s, Dr. Geppert highlights the mortality burden of the perinatal period, “Ninety-two percent of births occurred near term. Although the neonatal fatality rate in this group was less than 0.5%, it still accounted for 30% of the total neonatal deaths…. Birth occurred after the eighth month, but before term, in 6.6% of patients. Although 85% of these patients survived, this group accounted for another 30% of neonatal deaths.” Dr. Geppert also noted the frequent administration of not only routine vaccines, such as smallpox and diphtheria-pertussis-tetanus, but also typhoid, cholera, epidemic typhus, and yellow fever vaccines plus a Schick test (a skin test that assessed diphtheria protection) for children heading overseas with their families.

ABOUT LEO J. GEPPERT

Dr. Geppert’s impact on the field of pediatrics and military pediatrics in particular has had generational effects. Dr. Geppert, who was commissioned into the Army immediately after graduating from pediatrics residency in 1941, served as the executive officer and later commander of the 309th Medical Battalion, supporting the 84th Infantry Division and took part in the Battle of the Bulge. He was awarded the Bronze Star with “V” device for valor—a legacy that is reminiscent of the frontline service of military pediatricians in more recent conflicts.1 He subsequently established the first officially recognized department of pediatrics and pediatric residency program in the US Army at Fort Sam Houston’s Brooke Army Medical Center in 1947, 2 years before Colonel Ogden Bruton would establish the department of pediatrics and residency program at Walter Reed. Foreshadowing future advocacy of the American Academy of Pediatrics and its Section on Uniformed Services, Dr. Geppert’s scientific “pediatric needs assessment” in the military community would serve as the evidence base supporting his writings on the necessity of military pediatricians as part of Department of Defense’s support for a globally deployed force and their families. His dedication promoted the leadership role of the military pediatrician to advocate on behalf of their patients to support the necessary resources to provide excellent medical care to children and their families as a critical obligation in supporting the military mission.

References

  1. Burnett MW, Callahan CW. American pediatricians at war: a legacy of service. Pediatrics. 2012;129(Suppl 1):S33-S49
  2. Geppert LJ. Evolution of pediatric service in the US Army. US Armed Forces Med J. 1960;11:373-380


If Child-Resistant Containers Prevent Poisoning Can Safe Containers Prevent Gun Injury?

Melissa A Buryk, MD, FAAP

Affiliation: Department of Pediatrics, Portsmouth Naval Medical Center and Department of Pediatrics, Uniformed Services University

Highlighted Articles From Pediatrics

In 1969 Colonel Robert Scherz published a landmark study entitled, “Child-Resistant Containers Can Prevent Poisoning.” At that time, nearly 1 million non-fatal poisonings occurred per year. Many of these poisonings were accidental ingestions by children under age 5. A team of military pediatricians, led by Dr. Scherz, an army pediatrician, sought to reverse this trend through use of a novel safety device. An innovative child resistant lid coined the Palm-n-Turn, capped the 270,000 containers used for all prescriptions distributed from the military facility pharmacies. He described that the number of poisonings had decreased by 90% 1 year after introduction of the Palm-n-Turn. Accidental poisonings from prescription medications have continued to decrease dramatically since this 1969 publication.

By dissecting the successful components of this intervention, we can aim to apply the principles of these components to the challenges facing us today. First, the Palm-n-Turn lid embodied a simple and practical design that could vex even the most persistent child yet be easy to open for most intended users. Second, although the Palm-n-Turn lid was itself an effective safety device, the accompanying “child resistant” labeling also served as a visual reminder of the potential danger. Third, during the implementation and testing phase, the medication containers were distributed from a single point, allowing for successful follow-up and capture of outcomes from the intervention. Fourth, the new container was an inexpensive substitute that allowed easy scalability and buy-in from stakeholders outside the institution. Finally, the safety device was a built-in component of the product (the patient did not receive loose medication with instructions to secure the medicines in a childproof container that they could purchase elsewhere) and was dispensed as part of the prescription, which led to seamless implementation without imposition of additional financial or time burden on the consumer.

Today, firearms are the leading cause of death in children. In the December 2022 issue of Pediatrics, Lee et al outlined concise recommendations to decrease firearm-related injuries. The intersection between the principles behind the success of the Palm-n-Turn and the strategies outlined by Lee et al illuminate 3 key points. First, just as the Palm-n-Turn lid prevents or deters a child from opening a medicine bottle, a trigger lock precludes a child from activating a firearm. Second, the mere presence of the device serves as a reminder of the product’s danger. If a physician can prescribe a medication that is known to come with a child-resistant bottle, how can we develop a system in which a physician can prescribe a gun lock? Although individual firearms are not sold with a built-in locking device, would it be possible for pediatricians to provide patients direct access to a safety device to reinforce the urgency of safety, rather than advising them to purchase a gun lock? As was true at the advent of safe medication containers in the 1960s, the military health care system continues to provide health care in a somewhat closed system that facilitates access to stakeholders and tracking of population outcomes. Military pediatricians across the country have taken advantage of this capability in many ways. For example, our pediatric residency program at Naval Medical Center Portsmouth has begun a community outreach initiative to teach gun safety to the parents in their place of work rather than relying on the well-child visit for the instruction to occur. In its early stages, this initiative has received positive feedback, but additional data are needed to support its efficacy. Effective or not, the advice of a former naval officer and commander-in-chief, Theodore Roosevelt, can provide guidance: “In any moment of decision, the best thing you can do is the right thing…and the worst thing you can do is nothing.”

Second Quarter Century: November 1973 – October 1998

From “Wherever Practicable” to “Wherever”: Military Medicine’s Contributions to Neonatal Research in Pediatrics

LCDR Charles L. Groomes, MD, FAAP

Affiliation: Division of Neonatal-Perinatal Medicine, Walter Reed National Military Medical Center and Department of Pediatrics, Uniformed Services University

Highlighted Articles From Pediatrics

Long before the birth of neonatal medicine, an 1884 congressional appropriation bill called for military medical officers to provide care to dependents “wherever practicable.”1 Following World War II, and into the early part of the Cold War, a nascent military pediatrics community began to discover its central challenge and opportunity—that children of service members have unique needs and barriers to medical care. In response, just 1 year after the establishment of Pediatrics, the first military pediatric residency training program was accredited in 1949.1 Since then, a professional force of military pediatricians has been delivering care to our most vulnerable and deserving dependent children in both world-class military treatment facilities (MTFs) and in remote, austere locations across the globe. “Wherever practicable” is no longer the charge of a military pediatrician; it has become instead simply, “wherever.”

We highlight 4 papers published in Pediatrics in its second quarter century that demonstrate the indomitable spirit of uniformed pediatricians in those most perilous moments of our patients’ lives—birth and early infancy. Among these papers’ authors are veritable giants in military pediatrics, Colonel (retired, US Army) Errol Alden, MD, the former chief executive officer of the AAP, the late Colonel (retired, US Army) James Bass, MD, a world-renowned expert in pediatric infectious diseases, and the late Colonel (retired, US Air Force) Robert deLemos, MD, a father of neonatal research. Indeed, a 50-year-long plumb line can be drawn through these works to the mission of military neonatology and pediatrics today. Where there is a threat or challenge intersecting with the care of a military infant, our community has consistently risen to the occasion.

In 1974, Jennings et al, of Madigan Army Medical Center, published “A Teaching Model for Pediatric Intubation Utilizing Ketamine-Sedated Kittens.” In the 50 years since, ethical and logistic considerations have led the medical community increasingly away from the use of live animals for procedural training.2 The Fiscal Year 2013 National Defense Authorization Act3 called for the transition to human-based training, “when appropriate,” and subsequent studies have demonstrated non-inferiority of modern artificial simulators for emergency procedure training.4 These authors (including Dr. Alden), though, suggested that available training alternatives at the time were insufficient to generate confidence and mastery in the critical skill of endotracheal intubation during infant resuscitation. Their teaching model “fulfilled a needed requirement for medical personnel who may be called upon in pediatric emergencies.” Today, it is well-established that the appropriate management of the neonatal airway and delivery of effective ventilation are the most important interventions in infant resuscitation.5 With 40,000 live births in MTFs worldwide annually,6 maintaining uniformed pediatricians’ skills in neonatal airway management is a critical responsibility of our profession. As we continue to transition away from the use of live animal training to simulated and human-based training, it has become essential that these new modalities are effective in sustaining high-acuity, low-occurrence skills like neonatal intubation. In the spirit of Dr. Alden and his coauthors, current, former, and retired military pediatricians remain hard at work in those efforts.

Male infant circumcision has generated considerable passionate debate over the past decades. In 1985, Wiswell et al, of Tripler Army Medical Center, provided one of the earliest efforts at objectivity on the topic in their study, “Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants.” Dr. Bass, a coauthor of the study, would later contribute to guidelines on the management of infants with fever without a source.8 Dr. Wiswell and his coauthors demonstrated that uncircumcised male infants had a 20-fold greater incidence of urinary tract infection than circumcised males. Such efforts to provide an evidence-based approach to challenging clinical questions is a key contribution of military pediatrics. Managing septic infants in the remote or resource-limited settings where uniformed pediatricians practice is fraught with unique diagnostic and therapeutic risks; attempts to navigate those risks with objective data serve our patients and continue to serve the pediatric community. The AAP 2012 policy statement on circumcision has automatically expired (and not been reaffirmed, revised, or retired), but determined that the “preventive health benefits in male newborns outweighs the risks of the procedure.”9 The policy statement further emphasized, though, that those benefits do not meet the threshold to recommend universal male newborn circumcision, and that clinicians should discuss the procedure in an unbiased manner. As new information becomes available on the potential benefits of circumcision in preventing penile cancer and reducing the transmission and acquisition of sexually transmitted infections,10 the thoughtful conversation on this intervention will, and should, go on. Wiswell et al’s spirit of objective inquiry will serve as a foundation for that dialogue.

The field of neonatal medicine owes much of its foundational origins to the research conducted at Wilford Hall US Air Force Medical Center under the direction of Dr. Robert deLemos, beginning in the early 1970s. Indeed, Dr. deLemos and his team developed an early neonatal ventilator prototype from “spare parts,” recognized the importance of continuous positive end-expiratory pressure (PEEP) in treating respiratory distress syndrome (RDS), established a technique for noninvasive blood pressure monitoring in neonates, designed early platforms for global neonatal aeromedical transport (including en route extracorporeal membrane oxygenation, or ECMO), and introduced the use of high-frequency oscillatory ventilation (HFOV) in neonates.11 While “improvise, adapt, and overcome” has perhaps become an overused unofficial military slogan, Wilford Hall’s group of neonatal clinicians and researchers responded to a global mission requirement by exemplifying that principle in their ingenuity. In 1990, Carter et al, with Dr. deLemos as senior author, published a groundbreaking work entitled “High-Frequency Oscillatory Ventilation (HFOV) and Extracorporeal Membrane Oxygenation for the Treatment of Acute Neonatal Respiratory Failure.”2 This study demonstrated that even infants with cardiorespiratory failure refractory to conventional treatments can be rescued and survive through treatment with HFOV; further, those not responding to HFOV alone had excellent outcomes with subsequent ECMO. While not necessarily codified, in practice, this stepwise approach to supporting infants in hypoxemic respiratory failure has become the norm in neonatal care.12

Later, in 1992, Clark et al continued prior work on HFOV with their study “Prospective Randomized Comparison of High-Frequency Oscillatory and Conventional Ventilation in Respiratory Distress Syndrome.”3 This prospective, randomized trial sought to evaluate the comparative utility in using HFOV to prevent chronic lung disease (CLD) in premature neonates. Dr. Clark and his team found a significantly lower incidence of CLD at 30 days of life and 36 weeks’ postconceptional age for the infants receiving HFOV only, compared to those receiving conventional ventilation (CV) only (65% vs 30% at 30 days; P = 0.008; 38% vs 10% at 36 weeks’ postconceptional age, P = 0.013). The debate on the merits of HFOV versus CV for treatment of pulmonary dysfunction in preterm infants continues; a 2015 Cochrane Review demonstrated evidence that HFOV compared with CV may result in a small decrease in CLD.13 However, this review also emphasized the dramatically different between-individual responses to one method or the other, a concept well-known to clinicians and described by Dr. Clark.

References

  1. Callahan CW, Bass JW, Person DA, Shira JE. History of military pediatrics: fifty years of training and deploying uniformed pediatricians. Pediatrics. 1999;103(6):1298-1303
  2. Gupta AO, Ramasethu J. An innovative nonanimal simulation trainer for chest tube insertion in neonates. Pediatrics. 2014;134(3):e798-e805
  3. HR4310 112th. National Defense Authorization Act for Fiscal Year 2013. iv, 156 p. (US GPO: For sale by the Supt. of Docs, US GPO, Washington, 2013)
  4. Hall AB, Riojas R, Sharon D. Comparison of self-efficacy and its improvement after artificial simulator or live animal model emergency procedure training. Mil Med. 2014;179:320-323
  5. Weiner GM, Zaichkin J. NRP Textbook of Neonatal Resuscitation. American Academy of Pediatrics; 2021
  6. Office of the Secretary of Defense. Maternal and Infant Mortality Rates in the Military Health System. Department of Defense, ed. June 11, 2019
  7. Lopreiato JO, Sawyer T. Simulation-based medical education in pediatrics. Acad Pediatr. 2015;15:134-142
  8. Baraff LJ, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993;22:1198-1210
  9. Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):585-586
  10. Theoharakis M, Feldman E, Friedman S. Circumcision. Pediatr Rev. 2022;43:728-730
  11. Null DM, Yoder BA, DiGeronimo RJ. Early neonatal research at Wilford Hall US Air Force Medical Center. Pediatrics. 2012;129(Suppl 1):S20-S26
  12. Singh BS, Clark RH, Powers RJ, Spitzer AR Meconium aspiration syndrome remains a significant problem in the NICU: outcomes and treatment patterns in term neonates admitted for intensive care during a ten-year period. J Perinatol. 2009;29:497-503
  13. Cools F, Offringa M, Askie LM. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. 2015:CD000104


Transforming the Prevention of Respiratory Syncytial Virus infections

Martin G. Ottolini, MD, MEd, FAAP

Affiliation: Department of Pediatrics, Uniformed Services University

Highlighted Article From Pediatrics

It has been nearly 70 years since respiratory syncytial virus (RSV) was discovered to be the most ubiquitous and serious cause of bronchiolitis and pneumonia in young infants, especially those born preterm. Nonetheless, strategies to treat or prevent severe disease long have proved elusive. An early formalin-inactivated vaccine led to more severe disease with subsequent infection, which, along with the challenge of stimulating immunity in very young infants, have formidably challenged development of a safe and effective vaccine. Antiviral drugs have been unusually complicated to deliver, and at best only show marginal benefit in the most seriously ill patients. A myriad of bronchodilators and anti-inflammatory agents have not shown efficacy. Considering this, few may know that the exploration of immunoprophylactic and therapeutic approaches to prevent or treat RSV infection in infants stemmed from a serendipitous discovery by military pediatricians at Fitzsimons Army Medical Center in the late 1980s. These clinicians observed that an infant with RSV who had received pooled immunoglobulin in a study to reduce group B streptococcal disease recovered more rapidly than expected. The immunoglobulin preparation was later found to contain a high titer of anti-RSV antibodies. This story is related in detail in a supplement in Pediatrics in 2005.1

Investigators pursued further proof of concept of this intervention through a series of experiments in animal models, as well as small human trials, which indicated the efficacy of an approach using pooled high anti-RSV titer serum administered prophylactically to infants at higher risk for severe RSV disease. This led to the creation of a multicentered consortium involving the National Institutes of Allergy and Infectious Diseases, the Food and Drug Administration (FDA), a network of neonatal intensive care units, the Massachusetts State Health Department, the Henry M. Jackson Foundation for the Advancement of Military Medicine, and a newer company called Medimmune, all coordinated by Dr. Val Hemming of the Uniformed Services University, where the laboratory virology and antibody titers were performed. This seminal paper reports the positive results of the first larger randomized blinded clinical trial launched by this consortium, testing this concept in 249 children with either preterm birth or congenital heart disease. This study reported that administration of a higher dose of RSV immune globulin (RSVIG) to at risk infants significantly reduced both the incidence and severity of RSV lower respiratory tract disease. Despite these positive results, the FDA subcommittee felt this evidence was not compelling enough, leading to a more extensive 54-site clinical trial, which again proved the efficacy and safety of the prophylactic approach in reducing RSV disease severity and the number of hospitalizations due to RSV. These results were also reported in Pediatrics in 1997.2 The initial intravenous product, RSVIG, was subsequently licensed in 1997, and within a few years was replaced by the much easier to use intramuscular monoclonal antibody, palivizumab, whose similar protective results were also reported in Pediatrics in 1998.3

The prophylactic use of high titer anti-RSV antibodies has remained effective for over 25 years, and has reduced the morbidity and mortality from RSV for countless of our most vulnerable infants. Substantial progress has been made in the development of potential vaccines, which may eventually replace their use. In fact, the success of these interventions has supported one vaccination approach, which will utilize the strategy of maternal immunization to naturally provide newborn infants with a high titer of passive maternal antibody, which will hopefully protect infants during the most vulnerable newborn time frame.

References

  1. Ottolini MG, Burnett MW. History of US military contributions to the study of respiratory infections. Mil Med. 2005;170(4 Suppl):66-70.
  2. The PREVENT Study Group. Reduction of respiratory syncytial virus hospitalization among premature infants and infants with bronchopulmonary dysplasia using respiratory syncytial virus immune globulin prophylaxis. Pediatrics. 1997;99(1):93-99
  3. The IMpact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics. 1998;102(3):531-537


Third Quarter Century: November 1998 – Present

Twenty Years of Wartime Pediatrics: Still Grappling With the Lessons to Be Learned

Kevin M. Creamer MD, FAAP, Sara E. Bibbens DO, FAAP

Affiliation: Department of Pediatrics, Uniformed Services University

Highlighted Articles From Pediatrics

Currently there are 27 ongoing military conflicts worldwide that account for 80% of all humanitarian needs.1 Collecting data on pediatric wartime injuries is often done retrospectively and piecemeal at best. It radically underestimates the impact of war on children, with at least 104,100 verified killed or injured children in over 30 armed conflicts from 2005-2021.2 The 2 articles we showcase are representative of a much larger body of work attempting to quantify the impact of war on children, and the data-driven efforts to improve their care. Military pediatricians and surgeons who personally stood at the bedsides of these critically ill children authored much of the literature.

At the time of publication, the first highlighted article by Burnett et al was the largest observational study of children treated at military medical treatment facilities (MTFs) deployed to Iraq and Afghanistan.3 Children accounted for 4.2% of all admissions and 10% of occupied bed days and had a higher overall mortality when compared to adult non-US coalition patients (5.8% vs 4.5%).3 This landmark study brought attention to pediatric combat casualties and the need for improved pediatric trauma training.

Burnett et al’s work, cited 72 times in the literature, began to describe the extent of the problem and raised awareness beyond previously published case series. Their call to arms was echoed and amplified by multiple observational studies. Creamer et al (n=2060) and Borgman et al (n=7505) both found that children accounted for ~10% of all admissions to MTFs with disproportionately higher occupied bed days and mortality (6.9%-8.5%) compared to local national adults and coalition soldiers.4,5 The most common causes of death were head trauma and burns resulting from gunshot wounds and explosions.

The US Army Medical Command’s response included pediatric-specific predeployment trauma training, development of a pediatric critical care telemedicine service and a pediatric equipment and medication package, deployment of pediatricians to the busiest deployed MTFs, and inclusion of pediatric data into a centralized trauma database—the Joint Theater Trauma Registry (JTTR). Now known as the Department of Defense Trauma Registry (DoDTR), the JTTR gathered demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data that enabled critical analysis of the causes of child death during conflict.6 It also provided the necessary data for the creation and validation of the groundbreaking Pediatric Trauma BIG score reported by Borgman et al in our second highlighted article.7

Using the JTTR and a pediatric dataset from the German Trauma Registry (2002–2007), Borgman et al developed and validated a simple mortality prediction score for children with traumatic injuries. The BIG score (Base deficit + [2.5 × INR] + [15 – GCS]) quantified severity of illness (SOI) and correlated with the likelihood of mortality in pediatric trauma patients.7 While comparable to previously validated SOI scores, the BIG score did not rely on extensive clinical variables or require trained personnel. This breakthrough study has been cited 102 times and validated in multiple civilian trauma databases.8-9 The BIG score is accurate in both wartime (penetrating) and civilian (blunt) trauma populations; a score less than 16 has a high probability of survival while a score of approximately 26 correlates with a 50% mortality.

Explosive weapons have the ability to inflict maximal injuries to large groups. When this occurs, such as after the bombing at Hamid Karzai International Airport in August 2021, triage becomes the priority. Rapid determination of SOI and mortality risk with the BIG score quantifies physiologic derangement beyond clinical appearance alone and may allow providers to triage and allocate resources to those with the highest probability of survival. The BIG score also has an important use in civilian trauma. When patients have a BIG score above a set cutoff, it may help triage patients to appropriate levels of care and mobilize additional personnel/equipment in anticipation of a severely injured trauma patient.

Burnett, Borgman, and many others have made significant contributions to the care of pediatric casualties during armed conflict. Subsequent targeted analyses have led to deeper understanding of the impact of head trauma, burns, complex blast injury, and thoracic and vascular injuries on pediatric casualties. Despite these efforts, pediatric combat mortality continues to rise while adult mortality declines.10 Pediatric combat casualty mortality was 5.8% from 2001-2004, 6.9% from 2001-2011, and 8.4% from 2007-2016.3-5,11 It is imperative that we begin to adapt our pediatric combat casualty care in the same way as the Joint Trauma System (JTS) has revolutionized adult combat casualty care.

An aim of trauma performance improvement is to decrease variations from the standard of care. Data-driven analysis of triage and resuscitation, prehospital care, blood transfusion practices, damage control resuscitative surgery, and intensive care management from the DoDTR database continue to inform trauma research and to drive best practices. It also provides the foundation for ongoing systemwide education efforts to include updates to the second edition of the Borden Institute’s Pediatric Surgery and Medicine for Hostile Environments handbook—a novel pediatric doctrinal companion to the Army’s well known War Surgery Manual.12 The addition of a pediatric trauma clinical practice guideline (currently in development) to the JTS and a pediatric template for the operational medicine’s prehospital electronic health record will help guide pediatric care and minimize variation.

Moving forward, the United Nations has strongly advocated for prevention of civilian death in the war theatre—currently, 82 countries have endorsed the Protection of Civilians from the Use of Explosive Weapons in Populated Areas.13 However, it is paramount that we continue to improve pediatric casualty care from all angles, especially because children injured by explosives suffer a unique pattern of polytrauma.11 Although the majority of providers do not routinely encounter pediatric casualties, this low frequency of exposure to pediatric trauma leads to impaired medical readiness. Therefore, it is imperative to add additional pediatric trauma training with frequent repetition.

The landmark papers by Burnett and Borgman, and the painstaking work of so many others, undeniably highlight that wartime pediatric care at deployed MTFs is not an ancillary duty but an unfortunate yet intrinsic aspect of modern inpatient casualty care that demands better preparedness.

References

  1. Lowery T. 10 heartbreaking facts about ongoing conflicts around the world. Global Citizen. https://www.globalcitizen.org/en/content/facts-about-world-conflicts/. April 1, 2022. Accessed January 6, 2023
  2. Study on the evolution of the Children and Armed Conflict Mandate 1996-2021. United Nations. https://digitallibrary.un.org/record/3957892. Jan 2022. Accessed January 5, 2023.
  3. Burnett MW, Spinella PC, Azarow KS, Callahan CW. Pediatric care as part of the US Army Medical Mission in the Global War on Terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics. 2008;121(2):261–265
  4. Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu CE, Adelman W. Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions. J Trauma. 2009;67(4):762–768
  5. Borgman M, Matos RI, Blackbourne LH, Spinella PC. Ten years of military pediatric care in Afghanistan and Iraq. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S509–S513
  6. Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB. Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2006;61(6):1366-1373
  7. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma. Pediatrics. 2011;127(4):e892-e897
  8. Grandjean-Blanchet C, Emeriaud G, Beaudin M, Gravel J. Retrospective evaluation of the BIG score to predict mortality in pediatric blunt trauma. CJEM. 2018;20(4):592-599
  9. Davis AL, Wales PW, Malik T, Stephens D, Razik F, Schuh S. The BIG Score and prediction of mortality in pediatric blunt trauma. J Pediatr. 2015;167(3):593-598
  10. Howard JT, Kotwal RS, Stern CA, et al. Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017 [published correction appears in JAMA Surg. 2019 May 1]. JAMA Surg. 2019;154(7):600-608
  11. Schauer SG, Hill GJ, Naylor JF, April MD, Borgman M, Bebarta VS. Emergency department resuscitation of pediatric trauma patients in Iraq and Afghanistan. Am J Emerg Med. 2018;36(9):1540-1544
  12. Creamer KM, Fuenfer MM. Pediatric Surgery and Medicine for Hostile Environments. 2nd ed. Ft. Sam Houston, TX: Borden Institute, US Army Medical Department Center and School, Health Readiness Center of Excellence; 2016
  13. Dublin Conference to Adopt the Political Declaration on Explosive Weapons. https://www.inew.org/dublin-conference-to-adopt-the-political-declaration-on-explosive-weapons/. Nov 19, 2022. Accessed January 6, 2023.


Commentary on “Wartime Military Deployment and Increased Pediatric Mental and Behavioral Health Complaints”

Elizabeth Hisle-Gorman, PhD, Patrick Hickey, MD, FAAP

Affiliation: Department of Pediatrics, Uniformed Services University

Highlighted Article From Pediatrics

Parental separation from children due to war is a classic historical motif. Indeed, the impact of Odysseus’ separation from his son, Telemachus, fighting in the Trojan War serves as a central theme in Homer’s Odyssey. Despite the long history of parents going off to war, relatively little attention has been paid to the effects of parental wartime service on children. With extended military conflicts in Afghanistan and Iraq, there was heightened attention to the mental health impacts of combat operations on American servicemembers. More than 2 million children experienced the combat deployment of 1 or more of their parents. We highlight the 2010 Pediatrics article “Wartime Military Deployment and Increased Pediatric Mental and Behavioral Health Complaints” by Gorman, Eide, and Hisle-Gorman as one of a group of seminal papers published by the investigators that brought attention to the impact of parental deployment on children’s well-being.1

This study examined health record data from more than 640,000 children aged 3 to 8 years and found that during parental deployment, mental health care increased significantly, while care for all other categories of medical conditions decreased. This was the initial effort of a military-connected couple (GG and EHG) to understand and quantify the effects of deployment on children. Working in child protection and as a military pediatrician, both saw firsthand how families were disrupted by military deployments and later experienced the effects of deployments on their own young children. They applied their lived experience to explore this important topic. The authors recount sitting at the computer running the analyses. They found that decreased care rates characterized visit category after visit category with the exception of mental health care visits, which increased by 11%. Clearly, deployment was associated with increased mental health risk for children.

Since the publication of this and other noteworthy papers, advances have been made in clinical care, in appropriate resource allocation for families, and in research to better understand the issue of war and deployment on children and families. The department of pediatrics at the Uniformed Services University has established an academic division that is dedicated to understanding the unique impacts of military life on children. Aided by this growing body of research and resulting program improvements, civilian and military pediatricians can discuss deployment-related stressors with families, the latter assisted also by their own personal experiences shared in common with their patients’ families. On a programmatic level, the Department of Defense (DOD) has increased support to families with deployed service members through programs such as Healthy Steps, Family Support, Military OneSource, and DOD Education Activity Deployment services. Professional societies including the AAP and the Section on Uniformed Services, agencies of the Department of Health and Human Services, and even Sesame Street have webpages dedicated to informing pediatricians about deployment-related effects and clinical care resources.

Subsequent research has documented that during periods of deployment, children experience increased symptoms including worrying, sadness, and fear. Postdeployment parenting can be affected by the level of parents’ risk while deployed. Parental post-traumatic stress disorder (PTSD) related to combat deployment can have long-term detrimental impacts on parenting. Other studies have shown that in the year following parents’ return, mental health care continued to be increased, visits for children’s injuries and child maltreatment were also increased, and all of these types of care were further increased when a parent returned from combat with an injury.2,3

The work of Gorman, Eide, and Hisle-Gorman, and others who began this important work, have increased understanding of the risk to children consequent to parents’ combat deployment. Military pediatricians are spearheading efforts to identify and address adversity during childhood, food insecurity in military families, and early identification of children with developmental delay to implement effective care and to provide continuity when families move. Although these efforts to provide high-quality care to military families are part of a long history of military pediatrics, this paper was important to advancing the discussion in military pediatrics and DOD leadership of the unique stressors that military life places on families and our responsibility to provide excellent care to military families and children, which allows service member parents to complete their important work with less worry. While great strides have been made, additional efforts to meet the needs of these children and families to ensure child-family health and well-being must remain a military priority. The military pediatric community is well-suited to lead this effort.

References

  1. Gorman GH, Eide M, Hisle-Gorman E. Wartime military deployment and increased pediatric mental and behavioral health complaints. Pediatrics. 2010;126(6):1058-1066
  2. Hisle-Gorman E, Harrington D, Nylund CM, Tercyak KP, Anthony BJ, Gorman GH. Impact of parents’ wartime military deployment and injury on young children’s safety and mental health. J Am Acad Child Adolesc Psychiatry. 2015;54(4):294-301
  3. Hisle-Gorman E, Susi A, Gorman GH. The impact of military parents’ injuries on the health and well-being of their children. Health Aff (Millwood). 2019;38(8):1358-1365


Pediatricians Are Crucial Medical Providers for Our Military

Courtney A. Judd, MD, MPH, MHPE, FAAP

Affiliation: Department of Pediatrics, Portsmouth Naval Hospital and Department of Pediatrics, Uniformed Services University

Highlighted Article From Pediatrics

In February 2012, a series of 6 articles were compiled into a special supplemental issue of Pediatrics. These articles related part of the abundant history of the unique world of military pediatrics and highlighted the breadth and depth of contributions that military pediatricians have made across time and disciplines. This supplemental issue was originally drafted to commemorate the 50th anniversary of the AAP SOUS, which was approved as a section in April 1959.1 The scope of the project increased as the collaborators realized how many stories there were to tell. The authors and their peers represent some of the most influential uniformed pediatricians and SOUS members across the past few decades, and they are or have been clerkship directors, graduate medical education program directors, academic deans, department chairs, institutional leaders, faculty development stewards, prolific researchers, technological innovators, simulation experts, warfighters, humanitarians, and clinical champions in their fields.

Although this supplemental issue provided a few brief snapshots of the far-reaching impact of military pediatricians, our section’s compilation of noteworthy articles from the past 75 years of Pediatrics offers an even broader collage that further elucidates the richness and variety of the military pediatric heritage. The first article we chose to highlight was published in 1952, just a few years after Pediatrics was established. This telling of our story begins with the ground-breaking discovery of agammaglobulinemia by Dr. Ogden Bruton, who was a pioneer in the field of immunology and the study of primary immunodeficiencies. Subsequent articles cast light on the contributions of military pediatricians in the realms of epidemiology, public health and child safety, neonatology, medical education, simulation, immunotherapy, deployment medicine, mental and behavioral health, and pediatric trauma care. The final highlighted publication is this summary supplemental issue that connects our vast history with the present work of the SOUS.

Today, the SOUS is a dynamic group of nearly 800 members and is one of the largest sections within the AAP. SOUS members represent the Army, Navy, Air Force, Public Health Service, and civilian sector, and all of them are focused on promoting optimal health and wellness for military-connected children and their families. The SOUS benefits greatly from the powerful advocacy capabilities of the AAP as its members continue to prove how essential the work of the military pediatrician truly is. The current priorities of the SOUS strategic plan include consulting with the AAP Department of Federal Affairs on issues important to military-connected children and their families, addressing the mental health of SOUS members, and expanding the presence and impact of junior members as we train and equip the future leaders of military pediatrics.

Dr. Yu concluded his introduction in the military pediatrics supplemental issue with words that apply equally well to this latest journey through time, as we highlight and provide commentaries on notable scientific contributions made by uniformed pediatricians to Pediatrics over the past 75 years: “It is indeed a fascinating story, and one that the authors and I hope you enjoy reading as much as we have enjoyed assembling.” One can only imagine that the next 75 years will yield an even larger and more diverse tapestry in the legacy of military pediatrics.

  • Online ISSN 1098-4275
  • Print ISSN 0031-4005

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