New York The Epicenter of COVID-19: Challenges for Pediatricians

Asif Noor, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

A calamity brought to the elderly, I’m scared for
A virus being polite to the children, I cared for
A virus inflicting fellow pediatricians, I teared for
Please halt the spread in my town, I pray for

 Six weeks ago New York reported its first case of coronavirus disease (COVID-19).  We now stand more than 150, 000 cases and 6,200 deaths as of April 9^th,  2020.  New York has become the new epicenter of this pandemic.  It has affected every aspect of our lives.  Within days New York hospitals have been transformed into COVID units.  Bed capacity has been bumped up by 50 % as mandated by the New York State. Instead of cruise ships, a Navy hospital ship is docked at the Hudson River Bay.  Instead of exhibitions, Javits Center now holds 2500 beds.  The misery brought by COVID-19 has disproportionately inflicted our elderly especially those with underlying medical problems.

Pediatricians are facing radical changes as well.  Pediatricians are working side-by-side with adult colleagues in the hospital.  Pediatricians are providing virtual care using Telemedicine.  Pediatricians are at risk of getting infected while caring for the sick.  Several challenges to tackle at various fronts!

Let’s begin with the weekly morbidity and mortality report (MMWR) report on COVID-19 in Children.  Disease characterization in pediatrics was provided in this report published April 6^th, 2020.  ¹ In summary:

• Data from 149, 760 reported cases of laboratory confirmed COVID-19 was analyzed during February 12^th – April 2^nd, 2020.
• Cases in children < 18 years were low at 2,572 (1.7 %).
• New York State children comprised majority (56 %) of the cases in the US.
• Mean age was 11 years (0-17), one third of the cases are in teenagers 15-17 years (32 %).
• Majority of the pediatric patients were males (57 %).
• In terms of symptoms, 73 % of children had the characteristic fever, cough and shortness of breath when compared to adults (93%).
• Hospitalization information was available on 745 (29%) children. Among those 147 (estimated 5.7-20 %) were hospitalized and 15 admitted to the ICU (0.58-2 %).

These findings are similar to the data on children from China.  COVID-19 has been polite with the children.  Majority of the cases are mild with rare cases of severe disease in teenagers and infant particularly those with underlying medical conditions.

I would like to discuss:

1. Management of childhood COVID-19 pneumonia
2. Care for neonates exposed to COVID -19 infected mothers
3. Infection Control in office in midst of COVID -19 outbreak

• COVID-19 Management

As pediatricians we are familiar with management of viral infections.  The activity of high impact pediatric cold weather viruses, namely respiratory syncytial virus (RSV) and influenza (flu) is winding down.  RSV season is almost over, with only 1.2% of all the PCR tests during the first week of April. ²  Influenza activity continues to decrease sharply and it is low, only 2.1% during the last week of March.  There is also low activity of late winter and fall viruses such as human metapneumovirus and parainfluenza virus.

This implies that a child presenting with viral symptoms during widespread community transmission of SARS-CoV-2 is most likely to have COVID-19 infection.  Thereby it is of utmost importance that pediatricians who continue to see sick children in the office MUST have full personal protective equipment.  If you cannot safely provide office care then AAP recommend Telehealth visits.

If a child has confirmed or suspected COVID-19 infection based on symptoms (URI, fever, cough, shortness of breath) pediatricians should assess if these patients can be cared at home.  Most of the young children and youth who are otherwise well appearing can stay home.  Respiratory guidance should be provided regarding fever control with acetaminophen and hydration.  If an infant or a child with underlying medical problems (high risk group) or a child is deemed to have moderate to severe diseases i.e. difficulty breathing, they should be sent to emergency room for evaluation.

Hospital Care.

Based on the available hospitalization status in the MMWR summary, 157 children were reported to be hospitalized with 15 admitted to an ICU. Infants less than 1 years of age had the highest percentage (15-62 %) of hospitalization among the pediatric COVID-19 cohort.  All pediatric patients admitted to the ICU had one or more underlying medical conditions.

Children’s hospitals around the nation have adopted clinical pathways and algorithms to assist pediatricians with standardized care.  These guidelines take into account, a) evidence based care recommendations (evolving), b) protection of health care providers with adequate PPE, and c) best possible PPE conservative measures.  I will mention here few significant components of care:

Identification and isolation: Upon entry to the emergency room, any child with fever and/or respiratory symptoms such as cough or difficulty breathing should get a surgical mask.  Triage nurse as well as the healthcare providers providing initial care need to have surgical mask (if N95 is not available), eye protection, gloves and gowns.  If the child has moderate to severe disease or it is anticipated that the child needs an aerosol generating procedure (nebulization, intubation, nasopharyngeal swabbing [can induce coughing]), an N95 mask or PAPR should must be used by the provider in a negative pressure room.

Initial evaluation of suspected cases: Most of the Children’s Hospital have in house polymerase chain reaction (PCR) available now with a turnaround time of 4-6 hours.  Testing can also be done through the New York State Laboratory.  One nasopharyngeal swab should be obtained in children and transported in a viral transport medium.  In addition to COVID-19 testing, as clinically indicated, one should consider screening laboratory assessment with a complete blood count, inflammatory markers to asses cytokine storm (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], pro-calcitonin, ferritin, D-dimers, troponins) and complete metabolic panel. In children with severe presentation or underlying medical problems, consider sending interleukin-6 levels.  If I child has signs or symptoms suggestive of lower respiratory tract infection, a chest x-ray should be performed.

 Decision to send home: If there is no evidence of lower respiratory tract infection and the child does not have hypoxia the child should be sent home.  Instructions should be provided on home isolation, common infection prevention methods at home and quarantine of the household members for 14 days and a follow up visit, preferably a Televisit should be arranged.

Treatment for hospitalized cases:

Mild disease: Children with mild disease without hypoxia should be provided supportive care if the reason for hospitalization is other than COVID-19 infection.  Preferably, these children should be managed at home with Telemedicine/phone follow-ups.

Moderate to severe disease: In children with evidence of lower respiratory tract infection and hypoxia supportive care with oxygen, noninvasive ventilation and invasive ventilation is the mainstay of treatment.

 There exists no robust evidence on treatment options for COVID-19 infection. In the absence of strong literature, in the midst of this outbreak, it is reasonable to use anecdotal reports and weak evidence until better treatment options are available.  With every single case of COVID-19 pneumonia, pediatricians should balance benefit versus risk of treatment.

• Hydroxychloroquine and azithromycin combination for 5 days: Given in vitro activity of hydroxychloroquine against SARS COV-2 many medical centers including our institution is using hydroxychloroquine and azithromycin combination.  There is a clear lack of robust studies on this regimen at this time.
• In children with evidence of cytokine storm, as suggested by worsening of lower respiratory tract lung disease coupled with rising inflammatory markers and elevated IL6 levels, an interleukin-6 monoclonal antibody such as tocilizumab should be considered.  Anakinra, an IL 1 blocker has been shown to be beneficial in patients with cytokine storm and is currently being used at some centers.
• In children less than 18 years of age, with severe disease requiring mechanical ventilation, remdesivir can be obtained from Gilead: https://rdvcu.gilead.com/

Remdesivir is an adenosine analogue, which incorporates into RNA and causes premature termination.  It was shown to be effective in animal models against the previous SARS 1 and MRSA infections.  It can be obtained if you are a clinical site or may be obtained for compassionate use in children less than 18 years of age and pregnant woman.

• Others: Fever control medication of choice is acetaminophen over ibuprofen until more data on safety of ibuprofen is available.
• Use caution when using the following medications:
• Corticosteroids should be avoided, as WHO cited no mortality benefit and delayed viral clearance in SARS-1 infection.  One should refrain its use solely for COVID-19 infection and consider if there are any other reasons such as asthma.
• Generally we recommend against NSAIDs such as ibuprofen until more data on its safety is available in confirmed or suspected COVID-19 patients.

• Care plan for neonates exposed to COVID-19 mothers

Another challenge faced by pediatricians is regarding care of neonates born to mothers with COVID-19 infection. Neonates are considered vulnerable due to an immature immune system.  As a pediatrician, we strive and advocate for early skin to skin contact and promote benefits of breast feeding.  The concern of infecting neonates has led to a cautious approach until more data is available.

At our institution (unpublished data), about 30% of pregnant woman are COVID positive including asymptomatic mothers. American Academy of Pediatrics has provided guidance regarding this regard. https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.

In summary:

• When attending delivery, Airborne, Droplet and Contact Precautions should be utilized.
• Neonates are to be temporarily separated until mother’s symptoms improve (no fevers without antipyretics for at least 72 hours and improving respiratory symptoms) or two negative tests 24 hours apart.
• In addition, AAP suggests COVID-19 testing in neonates at 24 and 48 hours of life via a single swab, in the oropharynx and nasopharynx.
• SARS-CoV-2 has not be detected in breast milk. Mother with symptomatic diseases can express breast milk to be fed by infected caregiver.  Asymptomatic mother can breastfeed with good hygiene practice.

As we continue to care for neonates, we will encounter different challenges. COVID-19 is affecting families, thus many worry these babies will get exposed when they return home. Guidance should be provided to keep COVID-19 positive mother/any sick household members and the baby separated in different rooms or have at least a distance of 6 feet. As long as mother has symptoms, she should wear a mask.

• Infection Control in the Office.

During this outbreak, AAP recommends using Telehealth services to increase practice capacity.  At the same time, well visits for newborns and infant/toddlers/young children requiring immunization can be seen in the office, if able to arrange safely.  Well visits for older children and adolescent can be deferred to a later date.

A few tips for providing safe office care.

• Have different office times for well visits and sick visits.
• Have a separate space, if possible, for well visits and sick visits.
• At entrance, children with a fever, or respiratory symptoms should be given a mask and escorted to a separate room.  All health care providers should wear full PPE. New York State Department of Health provides infection control guidelines for evaluation of patients in outpatient setting: https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-infection-control-outpatient.pdf

References:

1. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. ePub: 6 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e4external icon.
2. https://www.cdc.gov/surveillance/nrevss/images/rsvstate/RSV14NumCent5AVG_StateNY.htm