The Coronavirus Disease 2019 pandemic by virtue of its sudden, unprecedented and widespread nature, has led to a multitude of psychological effects on individuals across societies. This includes anxiety which has important implications on the daily functioning, physical and mental health of individuals. Children are a vulnerable group of the population who can experience anxiety which potentially can lead to long-lasting implications on their health for years to come. It is thus important that their caregivers, including parents and healthcare professionals be aware of strategies that can help with anxiety in children. This article discusses anxiety in children in the context of the COVID-19 pandemic and outlines strategies that may be helpful.

As the coronavirus 2019 pandemic continues, healthcare services need to adapt to continue providing optimal and safe services for patients. We detail our adaptive framework as a large Developmental and Behavioral Pediatrics service in a tertiary academic institution in Singapore. The multidisciplinary team at our unit implemented various adaptations and workflow processes during this evolving pandemic in providing continued clinical care tailored to the challenges specific to our patient population. Services were continued via teleconsultation mode during the ‘Circuit Breaker’ (enhanced movement restriction) period. Specific workflow processes, IT infrastructure, and staff training were put in place to support smooth running of this service. Segregation of services into two teams based at two separate sites and implementation of stringent infection control measures surrounding the clinic visit by providers, patients and their families were incorporated to ensure safety. Measures were also taken to ensure providers' mental wellbeing. The clinical service was continued for the majority of our patients with a lowest reduction in patient consultations to half of baseline during the ‘Circuit Breaker’ period. We received positive feedback from families for teleconsultation services provided. We have been able to continue services in our DBP clinics due to our dynamic reassessment of workflow processes and their prompt implementation in conjunction with the hospital and national public health response to the pandemic. Given that this pandemic is likely to be long drawn, our unit remains ready to constantly adjust these workflows and make adaptations as we go along, together with the support for mental health of patients, parents and staff. Continual improvements in workflows will be helpful even beyond the pandemic to ensure good continuity of care for our patients and families.

Background: Amongst children presenting to an interdisciplinary clinic with complaints of picky eating, we aim to identify the proportion who have underlying selective feeding and to describe its implications on growth and nutrition, as well as parental coping responses. Methods: We conducted a retrospective chart review of first-visit consults from January 2020 to July 2022. Caregiver and child mealtime behaviours were assessed using the standardised Caregiver’s Feeding Styles Questionnaire (CFSQ) and by direct observation. Caloric intake and oromotor skills were assessed by dietitians and speech therapists, respectively. Medical concerns were addressed by the doctor. Results: Out of 152 children referred for concerns of “picky eating”, 128 (84.2%) were diagnosed as having selective eating, while the rest were diagnosed with delayed oromotor skills, poor appetite, oral aversion and 4 were deemed to have normal feeding behaviour for their age. Of the 128 selective eaters, 67 (52%) children had comorbidities such as autism spectrum disorder (ASD) (n = 59), attention-deficit/hyperactivity (ADHD) (n = 2) and underlying medical conditions (n = 6). The remaining 61 children were “otherwise well”. Of the “otherwise well” children, 47.5% had inadequate caloric intake and 31% had failure to thrive. The commonest feeding style among caregivers of “otherwise well” picky eaters was authoritarian (36%). The majority (80%) of these caregivers also experienced helplessness. Conclusions: We conclude that picky eating in young children is a symptom with several possible underlying aetiologies. It is associated with nutritional consequences for the child and significant stress on caregivers. Being able to recognise those who need referral for specialist intervention and multidisciplinary management (such as selective feeding and delayed oromotor skills) would be important.

CASE: Joseph is a 20-month-old boy who was thriving and developing well before a 4-day hospitalization for paralytic ileus at 11 months of age. Joseph is the first child born to parents who immigrated to the United States from Southeast Asia 3 years ago. Before the hospitalization, Joseph consumed 3 meals and 480 to 600 mL of milk daily. Oral feedings were restricted during the hospitalization with subsequent rejection of foods upon reintroduction of oral feeds. This resulted in 2 kg of weight loss by follow-up at 13 months. Joseph was referred to the multidisciplinary feeding and nutrition clinic at 16 months for failure to thrive, complicated by iron deficiency anemia and zinc deficiency. Joseph's feeding issues had negatively affected other aspects of his well-being; his development had stagnated, his sleep was fragmented (napping 5 times daily and frequent night waking attributed to hunger), and he had become withdrawn and irritable. By 16 months of age, Joseph was accepting only a couple of bites of solid foods by spoon or drinking small volumes (20–70 mL) of milk every 2 hours around the clock. Anthropometric z scores (World Health Organization) at 16 months: weight for age: < −3; length for age: −2.02; weight for length: −2.92; head circumference: −1.54. Physical examination revealed a cachectic and irritable child with loose skin folds. His skin was dry, and his hair was sparse. There were no perioral or perineal rashes, bruising, or features of rickets noted. Developmentally, parents reported that he was able to crawl and stand independently at the time of hospitalization, but by the time of evaluation at 16 months, he would no longer stand independently and tired quickly when crawling. He did not use any words but waved bye-bye, used gesture to indicate that he would like to be picked up, used a single-finger point to indicate his wants, and sought his parents for comfort. His fine motor skills were appropriate for chronological age. After extensive evaluation without findings of an organic cause for his failure to thrive, Joseph was diagnosed with avoidant restrictive food intake disorder (ARFID). Enteral nutrition was commenced using a nasogastric (NG) tube, and his micronutrient deficiencies were corrected. Joseph made significant gains within 2 weeks of beginning to receive enteral nutrition. Initial improvement in weight gain (25 g daily over 2 wk, resulting in weight for age z score improving to −1.85) was rapid. Joseph regained ability to stand and began taking a few independent steps. He also acquired the ability to use one word spontaneously and appropriately. His sleep improved, his previously cheerful disposition returned, and he became much easier to engage. Unfortunately, at 20 months, Joseph's parents chose to have the NG tube removed, and his growth began to falter. What would be your next steps in Joseph's care?

Background: The COVID-19 pandemic has been associated with rising obesity rates. Autistic children have a higher risk of obesity than neurotypical children. Our study aims to describe the changes in overweight/obesity rates in autistic children during the pandemic, and to identify contributing factors. Methods: This is a retrospective case record review of patients with a clinical diagnosis of autism, who were seen at a developmental-behavioral pediatrics clinic in a tertiary academic hospital, between 1 January 2019 and 24 October 2021. We compared the average monthly rates of overweight/obese status pre- and during the pandemic. We collected data on the patients’ and parents’ demographics, duration of screen time per day, degree of difficulties related to autism symptoms and cognition. We analyzed factors associated with being overweight/obese during the pandemic. Results: 1330 patient visits were included. The mean age was 45.4 months; 78% were male; 52% were Chinese. The average monthly rate of overweight/obese status increased by 1.8% during the pandemic (17.9% pre-pandemic; 19.7% during pandemic). Factors associated with being overweight/obese during the pandemic included: Malay ethnicity (OR 2.321, p < 0.01), developmental delay (OR 2.80, p < 0.01), and lower parental education level (father OR 1.73, p = 0.01; mother OR 1.63, p = 0.03). On multivariate analysis, only Malay ethnicity (OR 2.95, p = 0.01) was significant. Conclusions: Our study demonstrates a rising overweight/obesity rate amongst children with autism spectrum disorder during the pandemic. It also identified higher-risk patient profiles (Malay race, developmental delay, lower parental education). We hope this will facilitate the implementation of preventative health measures specifically supporting the high-risk children.