Collaborating to Advocate in Primary Care for Children During COVID-19
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Collaborating to Advocate in Primary
Care for Children During COVID-19
Elizabeth Harrison, MD, Jane Garbutt, MB, ChB, Randall Sterkel, MD, Sherry Dodd, BA, Ruoyun Wang, MS, MHA,
Jason Newland, MD, MEd, Katie Plax, MD, ST LOUIS REGIONAL PEDIATRIC COVID-19 LEARNING COLLABORATIVE
The St Louis Regional Pediatric Learning Collaborative of pediatric primary care abstract
providers and infectious diseases specialists formed in March 2020 to address the
needs of children and families during the coronavirus disease 2019 (COVID-19)
Washington University, St Louis, Missouri
pandemic. More than 400 pediatric primary care providers participated, using a
listserv to discuss care and organize webinars to provide updates on local and Drs Harrison, Garbutt, Newland, and Plax
conceptualized and operationalized the Collaborative
national data and plan next steps. To inform local decision-making about care and and designed the data collection instruments,
drafted the initial manuscript, and reviewed and
testing for severe acute respiratory syndrome coronavirus 2, 95 providers from revised the manuscript; Dr Sterkel conceptualized
26 practices partnered with the local practice-based research network to rapidly and operationalized the Collaborative, designed the
data collection instruments, and reviewed and
collect and share data about children with COVID-19–like symptoms. Of 2162 revised the manuscript; Ms Dodd conceptualized and
children tested for severe acute respiratory syndrome coronavirus 2, 9% had operationalized the Collaborative and designed the
data collection instruments, collected data,
positive test results. Test result positivity was 33% if a patient was exposed to a coordinated and supervised data collection, and
reviewed and revised the manuscript; Ms Wang
confirmed case of COVID-19 and 4% if they had COVID-19–like symptoms and no designed the database, conducted the initial
exposure. School or day care attendance was associated with lower rates of analyses, and reviewed and revised the manuscript;
and all authors approved the final manuscript as
positive test results. Although not originally planned, these findings drove local submitted and agree to be accountable for all
aspects of the work.
advocacy efforts by the Collaborative for increased access to testing and contact
tracing and safe in-person school. Members communicated directly and DOI: https://doi.org/10.1542/peds.2021-052106
collectively with local politicians, provided advice and resources for school boards Accepted for publication Jun 30, 2021
and superintendent groups, and appeared on various media platforms. In these Address correspondence to Jane Garbutt, MB, ChB, 660
South Euclid Ave, Campus Box 8005, St Louis, MO 63110.
efforts, they shared local data, highlighting the lower rate of positive test results E-mail: jgarbutt@wustl.edu
for children in school to support the idea that schools could be safely open. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Outreach from trusted pediatricians sharing prospective, timely, local data
Copyright © 2021 by the American Academy of Pediatrics
sustained in-person school for some districts and aided in future in-person
FINANCIAL DISCLOSURE: The authors have indicated
openings for other school districts. they have no financial relationships relevant to this
article to disclose.
FUNDING: Supported by the Washington University
Institute of Clinical and Translational Sciences
grant UL1TR002345 from the National Center for
Sometimes advocacy evolves quickly Pediatric Learning Collaborative (the Advancing Translational Sciences of the National
in response to urgent need. We Collaborative) with local pediatric Institutes of Health. The content is solely the
responsibility of the authors and does not
report on the opportunity for infectious diseases experts. The necessarily represent the official view of the
advocacy work realized during our Collaborative was operationalized National Institutes of Health. Additional funding was
provided by the Department of Pediatrics,
efforts to provide optimal care for through our long-standing practice- Washington University, and St Louis Children’s
children during the coronavirus based research network (PBRN) and Hospital. The funders did not participate in the
work. Funded by the National Institutes of Health
disease 2019 (COVID-19) pandemic. a newly implemented listserv. (NIH).
Early in the pandemic, pediatric Frequent webinars were held to POTENTIAL CONFLICT OF INTEREST: The authors have
primary care providers (PCPs) faced share local, national, and indicated they have no potential conflicts of interest to
disclose.
unprecedented challenges in caring international information about
for their patients. Given a lack of COVID-19, discuss concerns and
information about COVID-19 in experiences, and plan action steps.
children, PCPs in our community To cite: Harrison E, Garbutt J, Sterkel R, et al.
Initially, providers used the listserv Collaborating to Advocate in Primary Care for
were motivated to work together to
Children During COVID-19. Pediatrics.
optimize care. To this end, they to ask questions about patient 2021;148(4):e2021052106
formed the St Louis Regional management, such as the accuracy
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PEDIATRICS Volume 148, number 4, October 2021:e2021052106 ADVOCACY CASE STUDYand availability of testing for severe symptoms and rarely are severely or (45%) did not. Test result positivity
acute respiratory syndrome critically ill,2–9 local data from a rate for SARS-CoV-2 virus was 6%
coronavirus 2 (SARS-CoV-2), access cohort of children with symptoms for the group attending school and
to and appropriate use of personal suggestive of COVID-19 provided 12% for the group not in school,
protective equipment (PPE), and opportunity to identify P < .001, relative risk: 0.49 (95%
recommendations for quarantine. An discriminating factors for COVID-19 confidence interval: 0.34 to 0.71).
early concern was an inability to to guide testing decisions. Similarly, for the 883 forms that
distinguish COVID-19 from other provided information about
common childhood infections To this end, between June 1, 2020, attendance at a day care center, 267
especially in light of limited testing and October 16, 2020, 95 PCPs (30%) attended and 616 (70%) did
availability. These limitations prospectively reported data for not. The values for test result
included few test sites for pediatric 2162 patients who presented with positivity for the 2 groups were 3%
patients, long delays in receiving symptoms suggestive of COVID-19 and 11%, respectively, (P < .001,
test results, uncertainty about the and were tested for SARS-CoV-2 relative risk: 0.28 [95% confidence
accuracy of test results, and the lack (84% white, 6% African American interval: 0.13 to 0.57]).
of in-office testing due to shortages or Black, 3% multiracial, 2% other,
5% unknown; 4% Hispanic; 15% As we collected and analyzed our
of protective equipment and test
government insurance). Nine data, there began to be more focus
supplies. The challenges of accurate,
percent had positive test results. locally and nationally on the
timely diagnosis limited optimal
The majority of these patients had a potential educational, health
patient care, resulted in unnecessary
history of significant contact with a (including mental health), and
quarantine recommendations and
confirmed case of COVID-19 (59%) economic consequences of
created significant family hardship.
and had COVID-19–like symptoms prolonged school closures for
The Collaborative recognized that
(89%). The median number of children, especially for children of
testing and quarantine decisions had
symptoms at presentation was 3 color and those from a lower
critical effects on family functioning
(range 1 to 10). For many socioeconomic status.10–16 We
specifically regarding the impact on
symptoms, although statistically realized our unique opportunity as a
safe school and day care attendance.
significant in this large sample, the Collaborative to collectively use our
difference in frequency between local data to advocate widely and
To address these concerns, the
children with and without COVID-19 often for children and their
Collaborative circulated a list of area
did not vary in a clinically families.17 Although disadvantaged
pediatric testing sites and
significant way. For example, the children were underrepresented in
collectively developed a clinical
most common symptom of runny our local data collection, our
testing algorithm on the basis of
nose or congestion was present in advocacy efforts intentionally
Centers of Disease Control and
66% of patients with COVID-19 and included school districts serving
Prevention recommendations at the
in 73% without COVID-19. Similarly, diverse populations. The goals of
time.1 The algorithm considered
cough was present in 48% with these advocacy activities were to
exposure to a known COVID-19 case
COVID-19 and 57% without. Using increase access to testing, provide
and presenting symptoms to inform
these local data, we learned that the optimal care for children, and to
testing decisions and clinical algorithm could not reliably
recommendations for return to support safe day care and in-person
identify those with and without school attendance for all children in
school or day care. To understand COVID-19. In effect, COVID-19
presentations of COVID-19 in our community.
cannot be ruled out clinically in
children in our community and most cases for children with viral
determine the utility of the METHODS AND PROCESS
symptoms, and, therefore,
developed testing algorithm, widespread access to reliable testing Over 4 months, 95 PCPs from 26
members of the Collaborative for SARS-CoV-2 was needed for practices spanning the greater St
worked with the PBRN to optimal patient management. Louis area participated in data
implement a mechanism to rapidly collection, sharing data on >2000
gather and share information about We also collected information about children presenting with
COVID-19 in symptomatic children school and day care attendance. COVID-19–like symptoms. In the
across their outpatient offices. Among the 1403 patient forms that absence of a common electronic
Although many studies have provided specific information about health record, the data were
revealed that children with school attendance, 767 (55%) collected prospectively by using a
COVID-19 typically have mild viral children attended school and 636 1-page form. This rapid data
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2 HARRISON et alcollection was possible because of The infrastructure provided by the letter in late July, signed by >70
the infrastructure of the PBRN was also important. pediatric providers and sent to 2 St
established PBRN, which provided Relationships among local pediatric Louis Congressional
expertise in data collection, data care providers and the PBRN were Representatives; the letter
entry and, when necessary, long-standing and tested. The PBRN advocated for more rapid use of the
obtained data sharing agreements. has existed for almost 20 years and Coronavirus Aid, Relief and
Additionally, because the project was trusted by the community of Economic Security Act funds to
was to improve care locally, it was pediatric care providers to deliver expand SARS-CoV-2 testing and
determined not to be human help and support. This partnership contact tracing; because some of our
subjects research by the facilitated prospective data Collaborative members had long-
Washington University Human collection and storage of published standing relationships with elected
Research Protection Office. articles, reports and other resources officials, the letter was followed by a
that were relevant for providing phone conversation on next steps;
Findings from the data collection optimal care, advice, and advocacy our members of Congress then
drove advocacy efforts by members (http://wupaarc.wustl.edu/). The worked with local political officials
of the Collaborative. In addition to Collaborative served as a platform to improve partnership and
sharing local data within the group, to organize members in rapid communicated back directly to the
advocacy work included providing deployment advocacy activities. Let- Collaborative; (2) a letter sent in
advice and resources for school ters to local politicians were devel- August to the Saint Louis County
boards and superintendent groups, oped collectively via the listserv, and Executive advocated for in-person
appearing on various media resources for school boards were school; the letter was signed by
platforms and communicating shared via the PBRN Web site. close to 100 pediatric practitioners
directly with local politicians via Importantly, many members of the and addressed school mitigation
letters developed collectively and Collaborative already had relation- strategies of masking, social
signed by many Collaborative ships with local politicians and other distancing, and PPE and cleaning
participants. key decision-makers from past advo- supplies for schools. In addition, the
cacy efforts. These long-standing letter called for limiting large
Several factors were critical to the trusted relationships between gatherings and closing facilities
success of these advocacy activities. elected leaders and pediatricians associated with disease spread
The urgency and commitment of the provided greater access for discus- (bars, indoor gathering sites) while
providers to support the health and sion about pediatricians’ concerns maintaining in-person school.
wellbeing of their patients and and sharing of local data. Pediatricians reinforced the letter
patient families was essential. The with media work on television and
Collaborative ensured that providers OUTCOMES radio; this led to dialogue with the
banded together to receive group Advocacy to increase access to county executive and greater
support and advocated in concert SARS-CoV-2 testing through the pediatric representation in
together. In addition, infectious local hospital system was workgroups that included school
diseases specialists provided the unsuccessful for many months. superintendents and the metro-wide
most up-to-date knowledge and However, PCPs increasingly COVID-19 task force; (3) in early
expert opinion, shared local and provided in-office specimen November, we developed a one-page
national data as they became collection for testing at private document outlining the results of
available, and participated in the laboratories, supporting each other the Collaborative data gathering
advocacy work. These specialists with information about local project; the document was
worked diligently to address laboratory resources, PPE presented to local public health
providers’ concerns in real time via purchasing, and advice about officials, political leaders, and school
the listserv and through webinars. operationalizing telemedicine and officials in various meetings; it
The uncertainty of the times meant parking lot visits. This alternative highlighted the lower rate of
prompt dissemination of shared new strategy rapidly increased pediatric positive test results for children in
knowledge was critical for access to testing in the community. school and day care, supporting the
participating pediatric care idea that local daycares and schools
providers, and this was a strong Regarding advocacy work to could be open safely; this one-page
motivator for participation and promote safe in-person school and document sustained in-person
ongoing engagement in both day care attendance, 3 activities school for some districts and aided
pediatric care and advocacy. seemed especially impactful: (1) a in future in-person openings for
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Downloaded 3other school districts; pediatricians increased resources for schools, and medicine and a listserv participant,
reinforced these results through it has encouraged pediatricians to provided 2 webinars covering care
continued engagement with local engage in advocacy efforts such as of patients with anxiety and suicide
school boards, private schools, and signing letters to state and federal risk assessment, each attended by
superintendent group meetings. politicians. However, in many >50 PCPs. These timely webinars
communities, decisions about school were especially relevant because
LESSONS LEARNED opening during the COVID-19 recent data reveal that emergency
Our experience revealed that pandemic are being made at the department visits for suspected
important and successful advocacy community level and have been suicide attempts among children
work by community pediatricians influenced by both local positivity aged 12 to 17 years has
can occur through a timely response rate and transmission dynamics as dramatically increased during the
to urgent needs. The goal of our well as local politics, including pandemic.24 Our PBRN has
project was to provide optimal care school boards. Our advocacy work disseminated resources and tools to
and improve access to in-person in this area was community based support primary care management
school and day care for local and rooted in what pediatricians of depression and anxiety through
children during the COVID-19 were seeing “on the ground” as the the listserv and is conducting
pandemic. It involved organizing pandemic unfolded, and it was interviews with providers to
pediatric care providers to follow supported by local data that aligned describe their experiences in
best practices that were constantly with the growing body of literature providing mental health care during
changing, standardizing testing in the United States about the safety the pandemic. We will use this next
recommendations during a of in-person school.20–23 The need round of local data to advocate for
confusing time when consensus for for advocacy was clear to providers, needed services for children in our
pediatric patients was lacking, and and, therefore, strategies were community.
collecting data to inform future quickly developed, shared through
decision-making for schools and listserv discussions, webinars, and CONCLUSIONS
daycares. Although not originally other means and then rapidly While working together to provide
planned, all of these activities deployed for action. Many members optimal care for families in the face
provided opportunities for local of the Collaborative already had of great uncertainty, our
PCPs to use their shared knowledge ongoing relationships with local Collaborative accomplished many
to advocate widely in our politicians and school boards from advocacy goals focused on the needs
community for improved outcomes previous involvement, so these were of children and families during the
and opportunities for children. This leveraged to increase pediatrician COVID-19 pandemic. We conclude
advocacy supported local school influence on groups making that timely advocacy efforts can be
leaders and public health officials to decisions at the local level. Both effective when pediatric providers,
help most local schools open. newly forged and ongoing both community and academically
relationships were critical to the based, band together with shared
Our project revealed that pragmatic success of the advocacy activities goals. In our case, the Collaborative
collaboration between community- reported here. was able to rapidly gather local data
based PCPs, academically affiliated about COVID-19 in children and
pediatric infectious diseases experts, The Collaborative listserv is now influence school reopening decision
and a PBRN led by academicians cemented in our community as a using letters, media, and
could effectively organize advocacy collegial network that offers an relationships built with local
efforts during the COVID-19 effective platform for timely leaders.
pandemic. National organizations problem solving and support. As of
like the American Academy of June 14, 2021, the total number of Current efforts of the Collaborative
Pediatrics and the American Medical participants on the listserv is 447. are focused on the continuing
Association have provided structure Providers continue to answer challenges for primary care
and resources to support physicians questions and share information, providers presented by COVID-19,
in caring for patients during the and experts are consulted for advice. specifically the increased demand
pandemic.18,19 The American For example, in response to recent for mental health care associated
Academy of Pediatrics has questions and discussion about care with the pandemic. This work
advocated at the federal and state for pandemic-related mental health presents an opportunity to advocate
level for financial relief for patients issues for children and teenagers, Dr for a coordinated system of mental
and providers, access to testing, and Katie Plax, an expert in adolescent health care in our community to
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4 HARRISON et aloptimize outcomes and use of Calfee, MD, Erin Casey, MD, John Skoultchi, MD, Carolyn Smith, MD,
resources. As children’s hospitals Cole, MD, PhD, FAAP, Lora Collier, Joshua Smith, MD, David Sonder-
continue to sound the alarm of the MD, Tracy Cope, RN, MSN, CPNP, man, MD, Robert Spewak, MD, Craig
behavioral health crisis and Alison Cosa, RN, FNP-C, Kristine Spiegel, MD, Kristin Stahl, MD, Lacey
difficulties in caring for these Costello, FNP, Teresa Dillard, CPNP, Stevenson, PNP, Marissa Stock, MD,
children, efforts among primary care Alla Dorfman, MD, Julie Dorfman, Kristen Terrill, MD, Cassandra Wal-
clinicians to fill the increasing gap in MD, Jennifer Dunn, MD, Adam lace, PNP, Karen Whiteside, MD,
mental health care services for Eaton, MD, Jay Epstein, MD, Diane Kristine Williams, MD, MPH, Latoya
children is ever more critical. Eschmann-Morie, MD, Rose Eslinger, Woods, NP, Kathie Wuellner, MD,
PNP, Kora Felsch, MD, Isabel Fer- FAAP, Staci Young, MD, and Daisy
Although clinicians who care for nandez-Holtzman, MD, Maria Gan- Zhou, MD.
children from disproportionately ninger, MD, Caryn Garriga, MD,
impacted racial groups participate in Elizabeth Hammer, MD, Suzanne
the listserv, few of these clinicians Hanson, MD, David Hartenbach, MD, ABBREVIATIONS
participated in the data collection Amy Hauch, MSN, RN, CPNP-PC,
COVID-19: coronavirus disease
project, resulting in Mary Jo Hernandez-Zipfel, MD, Jane
2019
underrepresentation of these Hicks, CPNP, Laura Hill, MD, Laura
PBRN: practice-based research
children in our sample. A goal of the Holzum, MD, Anna Huger, MD, Marti
network
Collaborative is to engage more Ianiri, CPNP, Virginia James, RN,
PCP: pediatric primary care
primary care clinicians who provide MSN, CPNP, Angela Jones, MD, Pam
provider
care to populations of racially Kane, MD, Karla Keaney, MD, Stefa-
PPE: personal protective
diverse children and children living nee Keth, MSN, RN, CPNP-PC, Joel S.
equipment
in poverty to extend the reach of Koenig, MD, Katherine Komendow- SARS-CoV-2: severe acute
this work and expand opportunities ski, MD, Valerie Kover, MD, Katy respiratory
for local advocacy. Kreusser, MD, Abby Kushnir, MD, syndrome
Liling Lai, MD, Kenneth Levy, MD, coronavirus 2
The unique challenges faced during Stephanie Lorts, MD, Christine
the pandemic drove the Machicao, CFNP, John Madden, MD,
development of our Collaborative, PhD, Julia Mayer, MD, Jina McAtee,
which will certainly continue to REFERENCES
MD, Maggie McCormick, MD, Andrea
shape primary pediatric care in McCulloch, RN, CPNP, Thomas C. 1. Centers for Disease Control and Preven-
our community moving forward. It McKinney, MD, Kristen Mennemeier, tion. Overview of testing for SARS-CoV-2
is a clear demonstration that (COVID-19). 2020. Available at: https://
MD, Shilpa Menolascino, MD, Mary
collaboration among academic and www.cdc.gov/coronavirus/2019-ncov/hcp/
Meyer, MD, Jenny Miele, MD, Maya
community pediatricians is testing-overview.html#previous. Accessed
Moody, DO, Andrea Mouldon, RN, January 13, 2021
essential to ensure the best care PNP, Steven Mueth, MD, Kevin Mur-
for our children and families. Our 2. Dong Y, Mo X, Hu Y, et al. Epidemiology of
phy, MD, Alison Nash, MD, Gina Nel-
model has great potential for COVID-19 among children in China.
son, PNP, Karen Norton, MD, Sarah Pediatrics. 2020;145(6):e20200702
effectively addressing future new O’Grady, MD, Jerome O’Neil, MD,
or rapidly evolving pediatric health 3. Centers for Disease Control and Preven-
Andrea Orr, MD, Alison Oswald, MD,
crises here and in other tion COVID-19 Response Team. Coronavi-
Jennifer Panasci, MD, Rinkal Patel,
communities. rus disease 2019 in children—United
MD, Lori Payne, CPNP, Danny Plax, States, February 12–April 2, 2020. MMWR
MD, S. Bo Plurad, DO, Cassandra Morb Mortal Wkly Rep. 2020;69(14):
ACKNOWLEDGMENTS Pruitt, MD, Peter Putnam, MD, Jenna 422–426
St Louis Regional Pediatric COVID- Michaels Putzel, MD, MPH, Jamil
4. Parri N, Lenge M, Buonsenso D; Coronavi-
19 Learning Collaborative: Ardis Rana, MD, Dawn Roemer, CPNP, rus Infection in Pediatric Emergency
Allison, DO, Patricia Amato, MD, Sandeep Rohatgi, MD; Christine Departments (CONFIDENCE) Research
Courtney Andrus, PA-C, RD, Dana Ruby-Ziegler, MD, Lisa Ryan, MD, Group. Children with covid-19 in pediatric
Ankney, MD, Betsy Atkinson, MD, PhD, Elizabeth Satterly, MD, Marga- emergency departments in Italy. N Engl J
Robert Atteberry, MD, Sarah Aubu- ret Schmandt, MD, Jacquelyn C. Med. 2020;383(2):187–190
chon, MD, Cody Elizabeth Basciano, Schnidman, MD, Alicia Schumacher, 5. Kanthimathinathan HK, Dhesi A, Harts-
FNP-BC, Jean Birmingham, MD, MD, Colleen Seematter, MD, Rachel horn S, et al. COVID-19: a UK children’s
Trina Blythe, MD, Kristen Bruno, Shakofsky, MD, Kathleen Shaugh- hospital experience. Hosp Pediatr. 2020;
MD, Tara M. Budetti, MD, Archna nessy, CPNP, Paul Simons, MD, Alan 10(9):802–805
PEDIATRICS Volume 148, number 4, October 2021 from www.aappublications.org/news by guest on October 9, 2021
Downloaded 56. Zhang C, Gu J, Chen Q, et al. Clinical and during the COVID-19 pandemic - United coronavirus-resource-center-physicians.
epidemiological characteristics of pediat- States, January 1-October 17, 2020. Accessed April 11, 2021
ric SARS-CoV-2 infections in China: a mul- MMWR Morb Mortal Wkly Rep. 2020; 19. American Academy of Pediatrics. COVID-19
ticenter case series. PLoS Med. 2020; 69(45):1675–1680 response. Advocacy report. 2020.
17(6):e1003130 Available at: https://downloads.aap.org/
14. Dorn EH, Hancock B, Sarakatsannis J,
7. Otto WR, Geoghegan S, Posch LC, et al. Viruleg,E. Covid-19 and learning loss: dis- DOFA/COVID-19%20Washington%20Report
The epidemiology of severe acute respira- parities grow and students need help. %202.0.pdf. Accessed August 26, 2021
tory syndrome coronavirus 2 in a pediat- 2020. Available at: https://www.mckinsey. 20. Link-Gelles R, DellaGrotta AL, Molina C,
ric healthcare network in the United com/industries/public-and-social-sector/ et al. Limited secondary transmission of
States. J Pediatric Infect Dis Soc. 2020; our-insights/covid-19-and-learning-loss- SARS-CoV-2 in child care programs -
9(5):523–529 disparities-grow-and-students-need-help#. Rhode Island, June 1-July 31, 2020.
8. Bixler D, Miller AD, Mattison CP, et al; Accessed January 27, 2021 MMWR Morb Mortal Wkly Rep. 2020;
Pediatric Mortality Investigation Team. 15. Dorn EH, Hancock B, Sarakatsannis J, 69(34):1170–1172
SARS-CoV-2-associated deaths among per- Viruleg,E . COVID-19 and student learning 21. Gilliam WS, Malik AA, Shafiq M, et al.
sons agedCollaborating to Advocate in Primary Care for Children During COVID-19
Elizabeth Harrison, Jane Garbutt, Randall Sterkel, Sherry Dodd, Ruoyun Wang, Jason
Newland and Katie Plax
Pediatrics 2021;148;
DOI: 10.1542/peds.2021-052106 originally published online July 7, 2021;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/148/4/e2021052106
References This article cites 19 articles, 5 of which you can access for free at:
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Downloaded from www.aappublications.org/news by guest on October 9, 2021Collaborating to Advocate in Primary Care for Children During COVID-19
Elizabeth Harrison, Jane Garbutt, Randall Sterkel, Sherry Dodd, Ruoyun Wang, Jason
Newland and Katie Plax
Pediatrics 2021;148;
DOI: 10.1542/peds.2021-052106 originally published online July 7, 2021;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/148/4/e2021052106
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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