Vaccination Against COVID-19 and a MIS-C Update

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Theresa Fiorito, MD, FAAP

Theresa Fiorito, 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)

Dr. Theresa Fiorito, MD, FAAP is a member of the Infectious Disease Society of America, Society for Pediatric Research, Pediatric Infectious Diseases Society, American Academy of Pediatrics, and the International Society of Travel Medicine with a Certificate in Travel Health.

An entire year has elapsed since the first confirmed case of COVID-19 infection in New York. Pediatricians were in the forefront of an uphill battle during the spring outbreak and continue battling COVID-19 during the winter months.

Although children were largely spared, pediatricians encountered multiple challenges to which they responded methodically.  Whether it was protecting a newborn from maternal COVID-19, providing care to sick children in the office setting, dealing with mental health issues associated with the pandemic, or managing a novel condition in children, multisystem inflammatory syndrome in children (MIS-C), pediatricians promptly adapted.

On December 11, 2020, the FDA granted emergency use authorization (EUA) for the first COVID-19 vaccine by Pfizer/BioNTech.  As of February 6th, 2021, 59 million doses have been manufactured and 39 million have been administered in the U.S. Currently, the COVID-19 vaccine is being offered to the high-risk groups identified by the Advisory Committee on Immunization Practices (ACIP) based on the ethical principles of initial allocation. This includes pediatricians.  Many of us are thankful to receive it immediately after the EUA, particularly if we were associated with a hospital or medical center.  However, many of us working in an office witnessed firsthand the uncoordinated vaccine distribution with no clear guidance.

Children under 18 years comprise a quarter of the U.S. population and their immunization is vital to attain a goal of herd immunity.  Pediatricians are commonly questioned on the availability of COVID-19 vaccine in children.  The pediatric population needs to be immunized to not only protect them directly, but also to indirectly insulate the most vulnerable populations.

We, the pediatricians, serve as the primary advocate to deliver a clear and compassionate message on vaccine safety and efficacy.  Conducting COVID-19 vaccine trials in children is imperative alongside the vaccine rollout to the elderly and most vulnerable populations.

In this blog, we will review the basics of COVID-19 vaccines, vaccine eligibility, vaccination in pregnancy& lactating persons, vaccination in children, and an update on MIS-C.

COVID Vaccine: Pipeline

As of February 6, 2020, there are 67 vaccine candidates in human trials, with 4 vaccines fully approved for use worldwide. In the United States, the mRNA vaccines from Pfizer/BioNtech and Moderna are currently being utilized.

Vaccine target: The major antigenic target for COVID-19 is the large surface spike protein.  This antigen allows the virus to bind to angiotensin-converting enzyme 2 (ACE-2) on the host cell and induce membrane transfusion.  A vaccine that can induce antibodies against the receptor binding protein of spike protein can prevent attachment to the host cell and neutralize the virus.

Vaccine platforms:COVID-19 vaccines are being developed using different platforms. As pediatricians, we are familiar with the traditional approaches applied to inactivated vaccine (e.g. inactivated influenza) and live vaccine (e.g. measles) technology.  The genetic sequence of COVID-19 published on January 11, 2020, led to a rapid emergence of new vaccine research and collaboration. It paved the path for the first two vaccine candidates currently authorized for use in the United States, using an mRNA platform.  Other vaccine candidates use replication–incompetent vector vaccines, recombinant protein vaccines, etc.

COVID-19 vaccines in the United States

Approved vaccines

Upcoming vaccine candidates

Candidate

BNT 162b2

Pfizer/BioNTech

mRNA1273

Moderna

Janssen

Johnson & Johnson

AZD1222

AstraZeneca

NVX-CoV 2373

Novavax

 

Platform mRNA mRNA Adenovirus 26 Chimpanzee adenovirus Recombinant nanoparticle
Doses

2 doses,

21 days apart

2 doses,

28 days apart

Single dose

2 doses,

28 days apart

2 doses,

21 days apart

Efficacy 95% 94.1%

77%

phase III in U.S.

70.4 %

phase III in U.K and Brazil

89.3 %

phase III in U.K

 

mRNA technology: The mRNA is delivered in lipid vesicles. After administration, the mRNA is translated into the target protein which is intended to elicit an immune response.  The mRNA does not enter the nucleus or interact with host DNA.  The normal cellular processes degrade it quickly.

Immunogenicity and efficacy: Phase 2 (small scale immunogenicity, safety and efficacy trials) and phase 3 trials (large-scale safety and efficacy trials) have demonstrated the production of neutralizing antibody responses comparable to those in convalescent plasma from patients with asymptomatic to moderate COVID-19 infection.  Clinical trials have demonstrated vaccine efficacy of 95 and 94.1% in the Pfizer/BioNTech and Moderna studies, respectively, in preventing symptomatic COVID-19 infection after receipt of 2 doses.

Reactogencity (reactions that occur soon after vaccination; a physical manifestation of response): There are no serious safety concerns.  All vaccines elicit systemic adverse effects or reactogenicity such as fevers, chills, headaches, fatigue, and/or myalgias in a small portion of participants.  Most adverse effects are mild to moderate, and occur in the first 3 days after receiving the vaccine.  Symptoms are more frequent after the second dose, and in younger persons compared to older recipients.  Antipyretics or analgesics may be taken for post-vaccination local or systemic symptoms, however, routine prophylactic administration is not currently recommended.

Anaphylaxis following vaccination has been reported in an approximate rate of 5 events per 1 million doses. Out of these cases, 80% occurred in persons with a history of anaphylaxis, and 90% occurred within 30 minutes of vaccine receipt.

Vaccine effectiveness against variants: In the Pfizer/BioNTech cohort, the plasma from vaccinated clinical trial participants appeared to maintain neutralizing activity against the B.1.1.7, or the U.K. variant strain.  It also neutralized virus containing the key mutations in the B.1.351, or the South African variant, however the neutralizing titers were lower with South African strain.   Similar results have been found in Moderna’s in vitro neutralization studies.

COVID vaccine: Pregnant and lactating women

There are currently no safety data available on COVID-19 vaccines in pregnant persons. Data extrapolated from animal studies did not demonstrate any safety concerns in pregnant rats receiving the Moderna vaccine. Studies in pregnant animal models receiving the Pfizer/BioNTech vaccine are ongoing; it is of note that during the Pfizer/BioNTech clinical trials in humans, 23 persons became pregnant after receiving the vaccine, and to date, no adverse effects in these patients have been reported.

While absolute risk is low, pregnant women are at increased risk of severe illness from COVID-19 infection.  They may also be at increased risk of pregnancy complications, such as preterm labor. As per the ACOG (American College of Obstetricians and Gynecologists), COVID-19 vaccines should not be withheld from pregnant or lactating individuals if they are part of a group recommended to receive the vaccine (e.g., health care personnel, essential workers).  The Centers for Disease Control and Prevention (CDC) and ACIP also recommend that pregnant or lactating persons within eligible populations be offered the COVID-19 vaccine.  The Society for Maternal Fetal Medicine (SFM) advocates for all pregnant persons to have access to COVID-19 vaccines.

These organizations emphasize the importance of shared clinical-decision making; the decision for pregnant persons to get vaccinated should be based on an individual’s unique risk for infection.  For example, someone who is able to work from home through the entirety of the pregnancy has a low exposure risk, and may want to wait to get vaccinated until after the birth of the child.

Those trying to become pregnant do not need to avoid pregnancy after receipt of COVID-19 vaccination, nor is there any evidence that COVID-19 vaccination has any effect on fertility.

COVID vaccine: Children

Currently, the Pfizer-BioNtech mRNA vaccine is approved for ages 16 and up, and the Moderna mRNAvaccine is approved for ages 18 and up.

There is currently no COVID-19 vaccine available for children under age 16. However, studies in pediatric populations are ongoing.  Moderna is currently enrolling patients for a phase 2/3 randomized study to evaluate the safety, effectiveness, and reactogenicity in those 12-18 years of age. Pfizer is conducting a similar study in those 12-15 years of age.   Results of clinical trials on children under age 12 for both vaccines will likely take much longer, as dosing adjustments for age will need to be made.  AstraZeneca, whose COVID-19 vaccine is not yet approved in the United States (but is approved for use in the U.K.), also plans to commence clinical trials for those ages 5-18 years.  It is of note that obtaining study patients under age 12 is currently proving difficult; parents are finding it hard to justify enrolling their children in these trials.  While there is clearer evidence of spread of COVID-19 among teenaged children, transmission has been reported in those as young as age 8.  Given the accelerated nature of vaccine development, there is a preponderance of misinformation circulating, particularly online, regarding vaccine safety, which can contribute to skepticism and vaccine hesitancy.  As a pediatrician, we can identify concerns, educate patients on vaccine risks and benefits, and dispel the myths.  The most effective intervention against vaccine hesitancy is communication by a primary care provider.

Winter outbreak and multisystem inflammatory syndrome in children (MIS-C):  The initial emergence of MIS-C in New York was observed in May and June of 2020.  This preceded the peak of the COVID-19 epidemic in New York by 1-2 months.  In winter, a similar trend of MIS-C cases is being observed in January and February of 2021.

Much has been learned about the wide spectrum of clinical presentations and management of MIS-C.  Presentation ranges from a shock–like picture, to a Kawasaki disease-like presentation, to milder forms with brief febrile illnesses.  The median age of patients is 9 years.  All of them have fever, 88% have gastrointestinal (GI) symptoms, 60% have a rash, and 50% have conjunctivitis.  Children with fever ≥ 4 days without any source, with either GI symptoms, rash, conjunctivitis, oral mucosal changes, extremity changes, neurological symptoms, or lymphadenitis should be evaluated for MIS-C.

Some interventions such as intravenous immunoglobulin (IVIG)and/or prophylactic antithrombotic therapy are appropriate for most children presenting with moderate to severe disease, regardless of the dominant type of presentation. Children presenting with Kawasaki-type disease should receive standard therapies for Kawasaki disease such as IVIG and aspirin.  Children with cardiac involvement may present with arrhythmia and hemodynamic compromise.  Although IVIG can be used in myocarditis, the conclusive evidence of benefit is lacking.  In addition, based on severity of illness, low-dose methylprednisolone (2 mg/kg/day twice daily) or pulse steroids (30 mg/kg/day for three days) should be considered in hospitalized children.

Over the next 1 to 2 months, pediatricians should stay vigilant in triaging febrile illnesses that may be consistent with MIS-C in the office setting.

References:

  1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6947e3.htm
  2. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html
  3. https://www.cdc.gov/mmwr/volumes/69/wr/mm695152e2.htm?s_cid=mm695152e2_w
  4. https://www.acog.org/covid-19/covid-19-vaccines-and-pregnancy-conversation-guide-for-clinicians
  5. https://s3.amazonaws.com/cdn.smfm.org/media/2591/SMFM_Vaccine_Statement_12-1-20_(final).pdf
  6. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html
  7. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19
  8. https://www.clinicaltrials.gov/ct2/show/NCT04649151?term=pediatric&cond=covid-19+vaccine&draw=2&rank=3
  9. https://www.clinicaltrials.gov/ct2/show/NCT04368728?term=pediatric&cond=covid-19+vaccine&draw=2&rank=4
  10. https://www.nichd.nih.gov/sites/default/files/inline-files/NICHDCouncil_Erbelding_090720V2.pdf

COVID-19 Pandemic: The Effect on Well-Being of Children

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

 

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

 

Kyle Russell, DO, PGY3
Chief Pediatric Resident

 

The COVID-19 pandemic has been especially difficult for children despite mortality being lower than that of adults.  Specifically for children, they have had to deal with loss of loved ones, the stress of quarantine, and ever changing school landscape.  An overwhelming sense of fear and unknowing is present in these children, as none of them have had to deal with a pandemic of this nature and were unprepared for the difficulties of a global pandemic.  While the medical ramifications of Sars-CoV2 are rightfully the focus of the country, we have failed to acknowledge the significant psychiatric effects of this virus.

At the time of this publishing, there are over 23 million cases and more than 385,000 deaths attributed to COVID across the country.  Out of those 23 million, there are also hundreds of thousands, if not millions, of people who now have long term or lifelong morbidity due to this disease.  The worldwide death toll just hit over 2 million lives lost.  Children, if not affected themselves, are forced to come to terms with family members, many young or healthy, that have succumbed to this disease.  Often times, these are parents, grandparents, or other loved ones. In some cases, children have had entire households of their family die from COVID.  At a time that we are unable to see these family members before they pass or to attend funerals, it is even more difficult for children to cope with loss of loved ones.

Being isolated with family is extremely difficult for children and adults alike, even in ideal circumstances.  As many of us have found out, being isolated with family members for extended periods of time can be stressful for relationships.  The small living spaces in New York only exacerbate the high stress, as well as the potential infectivity for families.  However, there are many more cases where children are in less than ideal situations such as living with abuse, in subpar living conditions, or other unsafe conditions.  In these cases, being home is stressful and dangerous as is.  Due to shelter in place laws and quarantine, these children are being forced to spend additional time in these conditions is even more harmful for them.

In years past, school has been a constant in children’s lives.  However, this year, school has been nonexistent or vastly different than in the past.  As many of families know, it is exceedingly difficult to juggle online schooling.  New York’s cramped living spaces, parents working from home, having small children unable to work computers, and families without access to computers or internet all combine to make an extremely stressful and sometimes near impossible school experience.  Some children have difficulties learning online and also suffer from not being in the classroom.  Children also miss out on developing social skills with other children.  Classes such as gym and music also suffer when taught online.  When children were in school, resources such as in class teachers or helpers were decreased and children were unable to take advantage of the full resources as typical classes used to be.  Despite all the precautions taken, the spread of cases between children and to teachers was still a looming threat.  Children with special needs suffered the most from online or part time school.  Routines the additional resources offered to them were cut off, making it more difficult for them to learn and even more difficult for parents to take care of them at home, often while trying to work remotely themselves.

The number of children experiencing psychiatric symptoms has increased during the pandemic.  Young children have shown signs of psychiatric problems, such as inattentiveness, poor appetites, disturbed sleep, nightmares, more clinginess to caregivers, and significant separation problems1.  Children across the globe had increased rates of depression, anxiety, and posttraumatic stress symptoms from the pandemic than before2,3,4.  Similar to the long-term and possibly lifelong physical effects of COVID-19, we may see significant psychiatric effects on children and adults alike for long-term periods.

However, there are some resources for parents and children alike to aid them during these difficult times.  PBS provides parents with online resources to help teach children how to cope with these times6.  Likewise, Child Trends recommends the following to support and protect children’s emotional well-being during the pandemic5.

  • Understand that reactions to the pandemic may vary
  • Ensure the presence of a sensitive and responsive caregiver
  • Social distancing should not mean social isolation
  • Provide age-appropriate information
  • Create a safe physical and emotional environment by practicing the 3 R’s: Reassurance, Routines, and Regulation
  • Keep children busy
  • Increase children’s self-efficacy
  • Create opportunities for caregivers to take care of themselves
  • Seek professional help if children show signs of trauma that do not resolve relatively quickly
  • Emphasize strengths, hope, and positivity
  • Age appropriate yoga, mindfulness, or other forms of meditation

While COVID-19 has obviously ravaged this country with deaths and other medical morbidities, we have failed at acknowledging the psychiatric effects on the pediatric populations. Through age-appropriate teaching and facts, we can help to educate and prepare children for what is going on around them.  However, we need to be quick to refer these children to proper psychiatric help when deemed necessary.

References:


Five Steps Toward Becoming an Anti-Racist Pediatrician

Carley Gomes, MD

Carley Gomes, MD, FAAP

 

Carly Gomes, MD, FAAP, is a Neonatologist at Stony Brook Medical Center.  She serves as the Equity, Diversity and Inclusion Chair for New York Chapter 2

This year’s virtual American Academy of Pediatrics National Conference and Exhibition (NCE) featured perspectives of leading researchers and child health advocates on the adverse health and social/behavioral outcomes impacting non-white children and their families.  Systemic racism in the United States influences social determinants of health and contributes to inequities in health among minority children.  Although the clearest path towards improving the health outcomes of children of color would be to abolish racism, this is an overwhelming task to consider.  How do you begin to dismantle systemic racism when it is so ingrained in societal norms?  What can pediatricians do to elicit change and be advocates for minority children?

The AAP has taken the crucial first steps towards abolishing racism by formally identifying racism as an independent driver for health inequity in children and by apologizing for our organization’s own racist history.  Although many other medical groups have released statements addressing racial health disparities, the AAP is among the few to publicly acknowledge past discriminatory practices and the harm these institutional actions caused.

Through this process of recognition and reconciliation, the AAP has established itself as an anti-racist organization dedicated to promoting the health and well-being of all children.  As pediatricians and members of the AAP we can also do our part to establish ourselves as anti-racist health-care providers.

Below are 5 tips to get you started.

  1. Increase your exposure to different types of people and experiences.  Surround yourself with diversity.  This can be as simple as trying foods from different countries or learning about holiday traditions in other cultures.  Take a critical look at your social media profiles and photos to see who your friends and acquaintances are.  Though it’s comforting to associate with individuals with similar backgrounds and interests, challenge yourself to interact with someone very different from yourself.
  2. Self-reflect and identify your own biases.  Unconscious biases can increase during periods of stress or when you feel time-pressured.  Understanding your personal biases and being cognizant of times when these biases may become more pronounced is important in ensuring that they don’t significantly influence your thoughts and actions.
  3. Educate yourself.  Consider adding Ibram X. Kendi’s book, “How to be an antiracist,” to your queue.   Kendi served as the virtual NCE’s closing plenary speaker this year.  Familiarize yourself with the AAP policy statement on the impact of racism on child and adolescent health and learn more about how all children are adversely affected by systemic racism.
  4. Create a home and working environment that embraces inclusivity.  Set an expectation that racist commentary is unwelcome and encourage friends, family members, and colleagues to hold each other accountable for the use of racist or discriminatory dialogue.
  5. Advocate for change.  Find an outlet where you can safely speak up against racial injustice.  Make your voice and opinions heard by exercising your right to vote.  Let us all do our part to elect anti-racist officials who are committed to decreasing health inequities in children.  This year, more than ever, we need to vote like children’s futures depend on it.

References:


Vote for Children

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

(Dr. Shetal Shah, MD, FAAP is a neonatologist at Maria Fareri Children’s Hospital.  He is NYS AAP Chapter 2 President. This op-ed was published on Orlando Sentinel on September 16, 2020)

With only a few weeks until Election Day, voters are feverishly hearing from candidates running for offices from your local town board to president of the United States.  Though rallies, town halls and campaigning are mostly virtual this election season, candidates are articulating their visions and appealing to voters’ interests.  As an electorate, we are being demographically portioned into groups such as the “suburban” voter, the “millennial” voter or the “single-issue” voter.

However, one major constituency is not being highlighted in the current debate, which is why, as a pediatrician, I plan to vote like children’s futures depend on it in November.  Children are 20% of the population but 0% of the vote, and their problems don’t get addressed unless physicians, parents, teachers and those who care for kids make their issues are own.

Nothing is more fundamental to child health than health insurance and the ability to see a doctor when your child is ill.  For healthy children, insurance coverage allows kids to access preventive care like autism screening, vision/hearing/dental screening and life-saving immunizations.

But while the current COVID pandemic has highlighted disparities in children’s access to internet and quality virtual education, long-standing income-based gaps in children’s health insurance coverage have gone largely unnoticed.

Medicaid is the largest insurer of children, and along with Child Health Plus, covers about 39 million kids, including children in foster care and with special healthcare needs.  Deeper cuts to the millions of children covered by public insurance were only forestalled by the COVID-19 pandemic, but will be front-and-center next legislative session in every state as they grapple with budget deficits and coronavirus-related financial strain.

Nationally, we’ve seen an increase in the rate of uninsured children over the past few years. The COVID-19 pandemic, regulatory obstacles and reduced funding have led to over 425,000 children losing health coverage.  This reverses almost a decade-long trend of annual reductions in the number of uninsured kids. In 2016, only 4.7% of children were uninsured, the lowest rate ever recorded.

What did that mean?  It meant my patients with asthma could get inhalers and say away from the emergency room.  It meant more children with diabetes had access to insulin.  It meant more patients on my hospital’s oncology ward could receive chemotherapy.

I will be voting for kids because reduced Medicaid funding will harm my patients.  Patients like the extremely premature babies in my intensive care unit who — born the size of an iPhone — need special ventilators to breathe, medications to keep their hearts beating and customized intravenous fluids prescribed daily and adjusted hourly.  Half of all premature babies are covered by Medicaid and without a strong, well-funded program to support them, I fear they won’t get the physical, occupational and speech therapy they need to thrive.

Decades of data show children insured by Medicaid do better in school, graduate college and become healthier adults than if left uninsured and without access to a physician.  This makes Medicaid a good long-term investment as well. For every dollar invested in the program, the state receives a dollar in federal funds.

Protecting Medicaid locally and across the county is essential to the health of children.  That is why I plan to cast my vote with children’s needs in mind. The policies and laws and candidates we support today will impact our children.  Kids can’t vote, but I can vote like their futures depend on it.


Schools Prepare for Reopening

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Schools Prepare for Reopening:  COVID-19 and MIS-C and How it Relates to Parents, Teachers, Students, and Pediatricians

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

Kyle Russell, DO, PGY3
Chief Pediatric Resident
Wyckoff Heights Medical Center

Chenyu Zhang, B.S., OSM-IV
Medical Student
New York Institute of Technology College of Osteopathic Medicine

            As schools prepare for reopening, there are multiple factors to consider in order to ensure the best chance at a safe and secure reopening for children, teachers, and families. Schools across the country and the world have reopened with mixed results, which is why it is imperative to follow guidelines to give the schools the best chance of success.

Schools around the country have recently opened with various outcomes. Some school districts are able to have classes with no increase of spread yet while others have had staff deaths and subsequent closures. Community transmission rates have a significant impact on safely opening schools. New York City has had a positive test rate of less than 1% for the weeks up to the proposed school opening date4. The lower positivity rate leads to less asymptomatic carriers to potentially spread the disease.

However, recent reports show that 55 Department of Education employees have tested positive for COVID-19 in the week prior to the potential start date. Of those 55, at least 45 are teachers. This number is out of 17,000 tested, and marks a positivity rate around 0.3%4. While this number may be small, the potential for this to spread exponentially remains high, especially considering the amount of students, parents, and staff each of these people may come into contact with. To further complicate matters, these results are from tests administered two weeks prior to results, which allows a large window of potential infection time.

In order to decrease the spread of COVID-19 as much as possible, it is critical for students, staff, and teachers to stay home when symptomatic. The CDC reports symptoms of the SARS-Cov-2 virus may appear 2-14 days after exposure and include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. However, there are known asymptomatic carriers that can spread infection. Among them, children tend to be asymptomatic more frequently than adults3.  While previously believed that children were not significant carriers of the SARS-CoV-2 virus, recent studies have shown that they may carry similar or risk of transmission. While children tend to not have as severe of an illness than adults, they may be a significant vector to community spread 1.

Children are also at risk for developing Multisystem Inflammatory Syndrome in Children or MIS-C. MIS-C is known to be a possible sequela of  COVID-19. This is a serious inflammatory syndrome and your child’s doctor should be notified. Prevention for this syndrome is the same as prevention for COVID-19.

MIS-C Symptoms:

  • Fevers lasting for more than 24 hours
  • Red eyes and/or a skin rash
  • Abdominal pain, diarrhea or vomiting
  • Child seems confused or overly sleepy
  • Trouble breathing

In order to protect yourself, your child, and school staff members, simple prevention techniques should be used.

  1. Hand hygiene is critical, especially after touching door handles, subway rails, or other objects that come into contact with others.
  2. Social distancing, or staying 6 feet apart from others, helps decrease the odds that one comes into contact with respiratory droplets from another person who may be infected.
  3. Face coverings, such as surgical masks, fabric masks, or any other covering that covers both the nose and mouth decreases the droplets the wearer produces and therefore protects others. This is critical because even if one does not have symptoms, they may be an asymptomatic carrier or be early in the disease course and unknowingly infect many others.
  4. Eye shields could also prevent respiratory droplets from coming into contact with the mucosa of one’s eyes and may prevent transmission.

Schools have adapted methods in order to increase safety. Each day, children and staff members should have their temperatures checked and fill out a health screen prior to admittance. Schools are also offering different teaching styles to decrease interaction between children. The hybrid model includes a mixture of online learning from home and in-person learning, with many schools having students in school every other day to decrease exposure. For schools offering in-person learning, many are offering pod style classrooms. These pods have a smaller number of children in each classroom with an assigned teacher. This allows for less in person interaction by eliminating multiple teachers or staff members in classrooms, eliminating the need to change rooms, and limiting the number of children each student comes into contact with each day. In addition, school districts may also offer a full remote option, with all classes and assignments done virtually from home.

However, all of these options have both advantages and disadvantages. While a completely remote option is the safest for students and teachers alike, it requires supervision. A parent or caregiver would need to be home during learning. This inherently favors the wealthy, which are able to hire help to care for their children, afford to not work, or have a job where they are able to work from home. There is also concern for how effective remote teaching is when compared to in person learning. Pod style learning allows for children to continue in person learning and peer interaction with other students, but limits their potential exposure. By limiting the amount of people that work with the children restricts access to additional support, such as counselors and specialty teachers. Complete in person learning has the most traditional style that students are used to. Even with the improved methods for screening and sanitizing the environment, it has the highest exposure risk to teachers, students, and families alike.

Regardless of the route chosen by schools and parents alike, schools will require more resources. Schools will need staff to conduct symptom and temperature screenings, provide sanitizing solutions, and extra staff for smaller classes for in person training. For virtual learning, schools will need computers and cameras for staff to teach classes. Students will also need computers with cameras and microphones, as well as stable internet. This is difficult to ensure for all students, as 1 in 5 teenagers were unable to complete schoolwork at home due to the lack of a computer or internet connection5. This disproportionately affects Black, Hispanic, and low-income families.

Extracurricular activities are another benefit of attending school in person. Be it from participating in PE and art classes to the various clubs and sports most Middle Schools and High Schools offer, extracurriculars provide another layer of education and enrichment to our children. While this may not impact families with access to plentiful resources, in school art, music and PE classes may be the only exposure that a child from a low income family would have to certain art resources, a musical education, and various sports equipment. On the other hand, involvement in sports teams, especially contact sports, in school may increase the risk of transmission. Outdoor sports such as tennis, cross country and track would be less likely to be impacted by this pandemic. However sports such as football, soccer, lacrosse, baseball, and basketball involve moments where COVID would be spread. Swimming would be another activity where it would be especially hard for students to comply with mask regulations. As we learn more about the inflammatory and long term effects of COVID-19, we are also finding that patients are at a higher risk of myocarditis than other diseases, which is dangerous and could be fatal, especially with exertion during sports6.

Opening schools carries both significant positives and negatives. For those who opt into in person schooling, personal protection and infection control is critical. Schools should have a protocol in place for returning to school when sick, especially with influenza season arriving. In order to protect our children, their families, and school staff, self-quarantine when symptomatic, social distancing, and masking methods are imperative to curb the spread of COVID-19.

References:

1) https://jamanetwork.com/journals/jamapediatrics/fullarticle/2768952
2) https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
3) https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/symptom-screening.html
4) https://www1.nyc.gov/site/doh/covid/covid-19-data.page
5) https://www.pewresearch.org/fact-tank/2018/10/26/nearly-one-in-five-teens-cant-always-finish-their-homework-because-of-the-digital-divide/
6)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314071/

 

 

 

 

Racism is a Social Determinant of Health

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Racism is a social determinant of health – Pediatricians, children and their parents need to be a part of the conversation

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

Nguyen-Thao Tran, DO, PGY2
Department of Pediatrics
Wyckoff Heights Medical Center

As Pediatricians, our longstanding responsibility is to advocate for children’s health. The current events within our communities surrounding racism forces us to evaluate its role and the effect it has on children. Protests and civil unrest against racism took to the streets across America the last few weeks in response to the inhumane murder of George Floyd. Mixed emotions of anger, pain, confusion, stress and fear as a result of racial injustice are flooding social media and news platforms. The issue of racism at its core warrants conversations between parents and their children, with support by us as Pediatricians now more than ever. As Dr. Thomas J. Nasca, M.D., MACP, CEO of the ACGME stated in his recent letter to the community, “we as physicians bear a special responsibility to respond. It is our collective duty to advocate for all our patients, and to care equally and equitably for all our patients.” The special responsibility he mentions is to also “take on the challenging work required to solve deep rooted societal problems as they manifest in medicine.” Racism is a prime example of such a societal problem.

In 2019, the American Academy of Pediatrics (AAP) published a Policy Statement, “The Impact of Racism on Child and Adolescent Health.” In the policy, the AAP addresses racism as a social determinant of health. Children experience what the policy refers to as the “outputs of structural racism through place (where they live), education (where they learn), economic means (what they have), and legal means (how their rights are executed).” 1 The consequence of the inequality of access and attainment in education, based on the disparity of the social environment they grow up in has been shown to negatively impact their health and development as well as set the parameters for how kids understand race.1 Therefore, it is so important that the conversation of racism with children not be ignored. As Dr. Joseph L. Wright, M.D., M.P.H., FAAP, a member of the AAP Board of Directors stated in an AAP news release “if we are to progress in this country, it is going to be because we help our children, adolescents and young adults learn not just that racism exists, but that it is something all of us can work together to dismantle. Racism is not inexorable.”2

It is never too early to talk to children about race or racism. Rather, failure to talk openly with children about racial inequity contributes to the development of racial biases. Infants as young as 3 months of age notice race-based differences and begin to express preference by race; by toddler years, they internalize racial bias and begin to apply stereotypes and express biases; and by the age of 12 years it has been shown that most children become set in their beliefs.3

The AAP provides guidance for parents on how to talk to their children in an age-appropriate manner as outlined below: 1, 4

  • Check in with their child regarding what they know, what they have seen and how they are feeling.1, 4
  • Monitor for any changes in their children’s behavior. Children may internalize their feelings, expressing fear or anger. Parents are encouraged to reach out to their Pediatrician and/or mental health provider for additional support. Parents should also be aware of their own emotions and reach out for help as well, in order to develop their own coping strategies to refer to during these moments of heightened emotions. 1, 4
  • Limit screen time and exposure to the news. It is important however to recognize that if questions arise, parents do not avoid discussing the topic of racism. Parents should be encouraged to point out racial bias and stereotypes in the media, movie and/or TV shows. 1, 4
  • Use resources such as books during this teachable moment in history to address and recognize that racism still plagues our country. Children’s books are a practical tool for initiating these conversations. Children not only need to know what individual and structural racism looks like; they need to know what they can do about it. 1, 4 The Reach Out and Read (ROR) program recently took the initiative and will be diversifying the book selection to help support the conversation about race, racism and resistance. Below are links to a ‘Medical Provider Crisis Guidelines6 and a ‘Virtual Learning Resources for Young Learners and their Families7 put together by the ROR of Greater New York.

Pediatricians can play a pivotal role in helping kids and families discuss the current events regarding racism and the protests taking place nationwide. We can help children and their families build empathy and embrace diversity by discussing racism and racial justice during pediatric visits. To do so, we also need to check our own biases, create a culturally safe medical home for our patients, and continue to actively advocate at the local as well as federal level the policies that will bring about advancing social justice and change.1,5 In this manner, our collective voice and action will help reduce the inequities in education, housing and access to health care for all children.

References:

  1. Trent M, Dooley DG, Douge J, AAP SECTION ON ADOLESCENT HEALTH, AAP COUNCIL ON COMMUNITY PEDIATRICS, AAP COMMITTEE ON ADOLESCENCE. The Impact of Racism on Child and Adolescent Health. Pediatrics. 2019; 144(2):e20191765.
  2. Jenco, M. (2020, June 1). Dismantle racism at every level: AAP president. Retrieved June 18, 2020, from https://www.aappublications.org/news/2020/06/01/racism060120
  3. Anderson, A., & Douge, J. (2019, July 29). Talking to Children About Racial Bias. Retrieved June 18, 2020, from https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/Talking-to-Children-About-Racial-Bias.aspx
  4. Heard-Garris, N., & Douge, J. (2020, June 1). Talking to Children about Racism: The Time is Now. Retrieved June 18, 2020, from https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/Talking-to-Children-about-Racism.aspx
  5. American Academy of Pediatrics Addresses Racism and Its Health Impact on Children and Teens. (2019, July 29). Retrieved June 18, 2020, from https://www.healthychildren.org/English/news/Pages/AAP-Addresses-Impact-of-Racism-on-Children-and-Teens.aspx
  6. Medical Provider Crisis Guidelines: https://drive.google.com/file/d/15wYVQHqlZjuNiWtEYtyGPs6DgpVfx7hV/view
  7. Virtual Learning Resources for Young Learners and their Families: https://docs.google.com/document/d/1893FrURp664uUFmHS0rO1R_f_f9K_4wObzMU9p78oTU/edit

See and Not Miss The MIS-C

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Leonard Krilov, MD, FAAP

Leonard Krilov, 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)

Dr. Leonard Krilov, MD, FAAP is Chairman of Pediatrics and Chief of the Division of Pediatric Infectious Disease at NYU Winthrop Hospital.  He is the Co-chair of the Infectious Disease Committee of the NYS AAP

See and Not Miss The MIS-C: What Pediatricians & Parents Need to Know About Multisystem Inflammatory Syndrome in Children Related to COVID-19

As of May 21st, there were 54,031 confirmed cases of COVID-19 in children in the United States. Children represent only 4.2% of all the confirmed cases nationally. It appears that children escaped the burden of severe lung disease associated with COVID-19. However SARS-CoV-2, posed a new challenge for the pediatricians in the form of a novel inflammatory syndrome.

On April 26th, pediatricians in the United Kingdom reported a severe inflammatory syndrome with Kawasaki like features in otherwise healthy children.1 These children tested positive for SARS-CoV-2 based on either reverse transcriptase polymerase chain reaction assay or /and serology. The initial UK case series described eight children presenting with persistent fevers, hypotension, and multi-organ involvement with evidence of inflammation. None of these children had respiratory symptoms.

Similarly, characterization on 35 children with cardiac failure in midst of COVID-19 was published from France and Switzerland.2 In Bergamo Province, a 30-fold increase in Kawasaki-like disease was observed in children. This followed a rapid recognition of analogous cases in New York. As of June 1st, there were over 200 cases with three pediatric deaths. New York State continues to collect data on children presenting with signs and symptoms suggestive of this inflammatory condition.

New York State has been on the forefront of developing guidelines on management. Our pediatric emergency departments quickly adapted screening procedures for children presenting with prolonged fevers (≥ 3 days). Instantaneously fever work ups for children included inflammatory and multi-organ system labs. Treatment regimens were promptly tried drawing an analogy to some components of Kawasaki disease. Most Centers are using intravenous immunoglobulins (IVIG) as the first-line agent, along with other immunosuppressive such as steroids and/or IL-1 blockers (Anakinra).

On May 14th, the Centers for Disease Control and Prevention (CDC) defined this new inflammatory syndrome temporally related to recent exposure of SARS-CoV-2 as the “Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19.

Centers for Disease Control has the following case definition:

Any child or young adult less than 21 years of age presented with:

Fevers

Laboratory evidence of inflammation

Severe illness requiring hospitalization

Multisystem organ involvement ( ≥ 2) such as cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurologic

AND

No alternate plausible diagnosis

AND

Evidence of recent or current SARS-CoV-2 by PCR, serology or antigen, or COVID-19  exposure 4 weeks prior to the onset of symptoms

 

This led to increased awareness by pediatricians as well as parents of MIS-C primarily from the news media. Despite development of plans for expeditious management strategies in the pediatric emergency room, there exists little guidance for pediatric offices in this regard. As the number of cases surge, a wide spectrum of MIS-C is acknowledged. In this blog, we provide a clinical pathway to triage children with fevers and concern of MIS-C presenting to the pediatrician’s office.

What is MIS-C? It is likely a post inflammatory response to recent infection by SARS-CoV-2. The clinical spectrum ranges from severe presentations such as shock-like presentation, macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH) syndrome to Kawasaki-like disease and milder variants manifesting as fevers and lab evidence of inflammation only. Abdominal pain is often a significant part of the presentation as well.

This is a general guidance and should be interpreted and applied with caution. It is expected to evolve as more information becomes available. Clinical judgment should supersede this clinical pathway.

 

Inflammation *Mild Severe Severe

Organ 

Involvement

No liver, kidney, heart involvement No liver, kidney, heart involvement Involvement of heart, liver or kidney
Next step
Follow up

 

Follow-up outpatient in

24 hours with repeat labs and refer to cardiology for Echo if still elevated

 

Send to emergency room for admission and follow-up labs and Echo

Sent to emergency room for further workup, admission and treatment consideration
*Mild CRP 10-40, Severe > 40  mg / L
Emergency Room Work up

 

     Clinical

Laboratory

 

SARS-CoV-2

  Inflammatory Organ involvement

□Shock-like presentation

□Kawasaki-like presentation

□ Fever only

 

 

□ ↑  WBC

□ ↑ CRP

□ ↑ Procalcitonin

□ ↑ Ferritin

□ ↑ ESR

□ ↑ D-dimer

□ ↑ Troponins

□ ↑ Transaminases

□ ↑ Creatinine

 □ PCR

 

□ Serology

 

□  Exposure

Obtain baseline echocardiogram, consider treatment with intravenous immunoglobulins +/- steroids + /- IL-1 blockers +/- IL -6 monoclonal

How to educate parents on MIS-C:

Parents should be encouraged to contact pediatrician if there is any concern about child’s health. While this inflammatory condition sounds frightening, the American Academy of Pediatrics reassures that this condition is rare. A blast email, phone texts, or phone calls to patient’s families in this regard will help with increased awareness as well as accessibility.

A script from American Academy of Pediatrics can be used, “MIS-C has been compared to another rare childhood condition, known as Kawasaki disease. Although it is different, if you notice any of the following symptoms please call your pediatrician:

  • Fevers lasting for more than 24 hours
  • Red eyes and/or a skin rash
  • Abdominal pain, diarrhea or vomiting
  • Child seems confused or overly sleepy
  • Trouble breathing

In addition, please let you pediatrician know if the child was tested positive for COVID-19 or exposed to this virus. Based on this information, the pediatrician will determine whether the child can be seen in the office, via telemedicine or you would need to go to the emergency department.”

As a pediatrician, please remember to report any such cases to the New York State Department of Health at (866) 692-3641.

References:


Mental Health Matters in the Month of May!

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

Christian McCartney-Melstad, DO, PGY1
Department of Pediatrics
Wyckoff Heights Medical Center

May is Mental Health Awareness Month and an excellent reminder to pediatricians to consider the mental health of their patients and their families at every visit.

This is even more important than usual, given the enormous disruptions caused at all levels of society by the COVID-19 pandemic.  Schools have been closed, children have been isolated with their families, and social activities have been cancelled or changed.  Families may be under enormous health, financial, and interpersonal stress.  Amidst all of these adjustments, mental health can become particularly vulnerable.

For young children, parents can adopt some simple steps to help children deal with these new fears and anxieties.

  • Talking with your child and ascertaining what they know about the coronavirus and COVID-19 can be a good place to start.
  • Answering their questions and reassuring them in an age-appropriate manner may ease their concerns.  Even if you don’t know the answers, voicing the child’s concerns may ease their anxiety.
  • Help your child understand that it is natural and normal to worry about these changes, and that everybody does.
  • Don’t try to protect or shield your child from news or current events.  The child may hear other, less-accurate information from their friends or online.
  • Be mindful that you model behavior for your child; if you exhibit anxiety or fear, they will perceive this.  Adults may need to be more thoughtful in how they express their emotions.
  • Teach your child that they are unlikely to become seriously ill, and that if they are sick, you will take good care of them.  Tell them what kind of support you have in case you get sick.
  • Help your child learn how to take proactive steps to protect themselves.  Practice handwashing, mask usage, and discuss the importance of social distancing.
  • Maintain as much normality in your lives as possible.  Try to keep some of your old, familiar routines.  This will help your child feel safe and stable.
  • Devote quality time to your child.  This can be challenging when everyone is at home together all day long, but it creates a space for gentle reassurance and an opportunity for them to voice their concerns informally.
  • Help your child think about actions they can take to feel safer.  Encourage them to pursue hobbies and relaxation.
  • Your child may want more close contact with you and feel more than usually anxious about separation.  Be prepared for more physical contact than usual.

School-aged children may have different concerns.  At this age, they may begin to take more comfort from facts. Parents can discuss some more of the science behind the disease with these children, and use informative graphs and figures to greater effect.  These kids can also be taught to distinguish truth from rumor, especially when considering anonymous or internet sources.  As with younger children, don’t try to disguise or conceal information: they’ll either get their information from you or from their friends.

Older children’s social needs are also more sophisticated.  Until it is possible to see their friends in person or return to school, consider setting up video calls or play dates.  Even short interactions can serve to maintain connections and decrease loneliness and social isolation.  Scheduling such calls in advance or making them part of the home school routine can help preserve a sense of predictability in the child’s life.

Teenagers’ needs are different than those of the younger or school-aged children, of course.  They may feel especially isolated as social distancing cuts them off from their friends.  The loss of milestone events like proms, graduations, and organized sports can be particularly difficult for them.

For teens, create a schedule that accommodates their online learning requirements.  Be flexible and allow “down time” and privacy.  Share the information that you receive from reputable sources and talk about how the can do their part to help slow the virus’s transmission by social distancing and practicing good hygiene.

Parents need to look after themselves, too!  Adults should take advantage of their social networks and healthcare resources to get the support that they need to best care for their kids.

Beyond these simple steps, we have identified several resources that pediatricians can use to help their patients and their families to understand the illness, the changes in their daily lives, and the importance of maintaining healthy habits in this time of uncertainty.

Organizations like ProjectTEACH provide many resources for pediatricians and their patients of all ages.

COVIBOOK” is a free PDF book downloadable in many languages that addresses young children’s emotions and explains the virus and its spread in simple language.

For older kids, “Coronavirus: A Book for Children” (also a free PDF) discusses the basic science behind the virus and its transmission, and specifically addresses the stress and difficulty of the social changes that children are dealing with, like staying home and not seeing their friends and family members.

There are abundant resources available online for parents, too.  The AAP’s own healthychildren.org website is an excellent place to start.  Other AAP resources, like the “Information for Families” webpage, add even more information. For comprehensive children’s mental health resources, parents can visit NYU Langone’s “COVID-19 Mental Health Resources for Families” website, the American Psychological Association’s page, or American Academy of Child and Adolescent Psychiatry’s resources.  Even mainstream publications like the USA Today have offered helpful advice.

Of course there are many, many other resources available online; many are of dubious quality.  With so many options, pediatricians can help their patients’ families by recommending high-quality, evidence-based information sources.

Resources:


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

Asif Noor, MD, FAAP

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 9th,  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 6th, 2020.  1 In summary:

  • Data from 149, 760 reported cases of laboratory confirmed COVID-19 was analyzed during February 12th – April 2nd, 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. 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
Management of COVID-19 pneumonia 
Supportive care, acetaminophen is the preferred antipyretic, avoid steroids unless another indication

Lack of robust evidence for the following:

o   Hydroxychloroquine and azithromycin combination for 5 days

o   If worsening respiratory status along with evidence of cytokine storm:

·       Monoclonal antibody against IL-6: tocilizumab

·       IL1- receptor antagonist: ankinra

o   Remdesivir, an antiviral available through Gilead for children < 18 years and pregnant woman https://rdvcu.gilead.com/


March 2020

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Dear NYS AAP – Chapter 2 Member,

As we all adjust to the changes in our lives brought about by COVID-19, I wanted to update you on what our Chapter, the National American Academy of Pediatrics, and the state and local government have been doing to assist patients and pediatricians during this time.  Like you, we are learning as we go and dealing with an ever-shifting array of regulations in both our personal and professional lives.  However, this is what has been done so far.
  • The New York State Department of Health has created a single website for all information related to COVID-19:  https://www.health.ny.gov/diseases/communicablecoronavirus/providers.htm The website includes medical information for healthcare providers.
  • For more pediatric-specific information, the National AAP has created a web resource for members: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/ and established an email address COVID-19@aap.org for questions related to pediatrics.
  • Dr. Lenny Krilov, Chairman of Pediatrics and New York University Winthrop Hospital at a Pediatric Infectious Disease specialist, recorded a short video about the importance of social distancing and handwashing which is available from multiple sources in Nassau County.
  • Both AAP Chapters 2 and 3 were consulted about the decision and timing of closing New York City Public Schools. Advocacy by senior NYS and Chapter leaders, particularly Drs. Lisa Handwerker (President, NYS AAP – Chapter 3) and Warren Seigel (Chair, NYS AAP District II), helped assure that the city implemented a plan to make school meals available to eligible students prior to closing until April 20th.
  • New York State released a downloadable PDF of a sign to assist triage of patients who enter a healthcare setting and may be exhibiting possible symptoms of COVID-19: https://health.ny.gov/publications/13076.pdf
  • Within hours of the announcement that schools in Nassau and Suffolk County would be closed for 2 weeks, Chapter 2 submitted a list of questions/concerns to the County Legislatures concerning the need to ensure healthcare workers receive priority for childcare and school services. As of this writing, that plan is currently being created.
  • The Chapter has reached out to the Departments of Health of Nassau and Suffolk Counties, and New York City, on behalf of its members in an attempt to secure Personal Protection Equipment (PPE), particularly gowns and N-95 masks – which many private pediatric offices do not stock and are unable to obtain.  All 3 departments have relayed that the shortage of PPE requires prioritizing ERs and hospitals, particularly intensive care units and therefore no other PPE is available.  In fact, conservation of PPE is actively occurring within hospitals due to concerns of a potential future shortage.  That said, all of these departments are aware of the critical role pediatricians will play in assessing the status of children, particularly those with primary caretakers in higher risk groups.
  • New York City recently announced that small businesses may be eligible for no-interest loans or grants if they can demonstrate significant financial losses from COVID-19.  The Chapter is working with officials in New York City to ensure that small pediatric practices which voluntarily reduced well-child visits during the pandemic as a means of reducing community spread are eligible. More information on these programs is available here:https://www1.nyc.gov/site/sbs/businesses/covid19-business-outreach.page
  • As Nassau and Suffolk Counties consider similar programs, the Chapter is working to ensure that small medical practices are also included.
It’s now been another week that we’ve been living and dealing with COVID-19 24 hours a day.  As always, we at the NYS AAP – Chapter 2 are inspired by the efforts of all our pediatric members to keep children safe during this pandemic.
As I reiterated a few weeks ago, I know you are getting deluged with emails, and that hospital regulations are changing (sometimes dramatically) daily.  Keeping up with all the information for yourself and your patients, adapting to new ways to delivering care, and just keeping our families together (and our kids from killing each other) is exhausting.  This is what your local AAP Chapter and the National AAP have been doing:
  • National AAP issued a “CALL TO ACTION” on behalf of pediatricians and other physicians to increase the availability/supply of Personal Protective Equipment (PPE).  The Chapter has partnered with Nassau County’s Office of Emergency Management to assist with distribution of Personal Protective Equipment.  The Chapter has already distributed ~300 masks and other PPE to pediatricians across Long Island.  Through our strong partnership with legislators across New York, the Chapter obtained a small amount of standard (non-N95) facemasks for outpatient, private pediatric practices.  The Chapter has stepped in to distribute about ~100 masks which general pediatricians can use to see children who require in-person visits in the office, thereby reducing the burden on emergency rooms.  Contact Jessica Geslani if you require a portion of this allotment.  Pediatricians that provide care in Nassau can complete the short online form available here: https://app.nassaucountyny.gov/OEM/supply-request/ to request equipment.  As we receive more, we will be distributing it accordingly.
  • The Chapter has also sent letters to all 11 of the Chapter’s federal representatives outlining the dire need for personal protective equipment, faster roll-out of point-of-care testing for COVID-19, a national stay-at-home order, and increased enforcement of current regulations.
  • At the onset of the COVID-19 pandemic, pediatricians in Chapter 2 realized that health plans covered under the Employee Retirement Income Security Act (ERISA) were NOT uniformly paying for telehealth visits, financially impacting pediatricians and reducing healthcare access during a time of public health crisis for up 5-8% of children in our Chapter.  Within TWO WEEKS, Chapter leaders brought this to the attention of Representative Tom Suozzi of New York 3rd Congressional District.  As a member of the powerful House Ways and Means Committee, he was closely involved in reviewing pending COVID legislation. Based on discussions with Chapter 2, Rep. Suozzi urged members of the House Education and Labor Committee to ensure that federal legislation REQUIRED these plans to cover telehealth services for both adults and children. The measure passed into law on March 27, 2020 as part of the “Coronavirus Aid, Relief, and Economic Security Act” or CARES Act. Chapter members should be proud of our role in detecting a loophole in federal policy and working expeditiously to close it in close partnership with our legislators.  Read the letter congratulating our Chapter on influencing national policy.
  • We are in contact with Tanuja Mohapatra of the New York State Department of Financial Services to ensure compliance of state-regulated health plans with telehealth.  If you are denied payment for a telehealth visit during the pandemic, please contact us.
  • Chapter 2 member and Pediatric Pulmonologist Dr. Melodi Pirzada from NYU Winthrop Hospital has answered questions from the public live on News 12 Long Island.
  • Dr. Eve Krief also participated in a “VIRTUAL TOWN HALL” on COVID-19 via Facebook LIVE.
  • Immediate Past President of New York Chapter 2, Dr. Steve Goldstein, made an appearance on MSNBC as one of several physicians calling for increased access to PPE.
  • Through our partnership with State Senator Jim Gaughran, our Chapter was THE STATE LEADER in ensuring that pediatric outpatient offices will qualify for Empire State Development and state Small Business Administration loans in New York. Until we brought this to the state’s attention, there was no consideration given to whether outpatient medical practices (themselves small businesses) would qualify.  Pediatric practices will be treated no differently than any other business and will be able to receive grants/loans based on their number of employees.
  • The Chapter partnered with local Girl Scout Troops and received donations of unsold Girls Scout Cookies which have been delivered to children’s hospitals within the Chapter.
  • We are considering starting a listserv, similar to the popular listserv on the National AAP’s Section on Practice Management, to help area pediatricians dealing with any COVID-19 issues.  If you are interested in having the Chapter pursue this, please contact me or Jessica Geslani at jgeslani@aap.org
  • Don’t forget to read our Pediatric Blog on COVID-19 by Dr. Asif Noor, available at: http://ny2aap.org/category/blog/
  • The NYS DOH’s COVID-19 Weekly Healthcare Provider Update Compilation provides healthcare providers in New York State with a consolidated update of guidance released by the New York State Department of Health (NYSDOH) related to the COVID-19 pandemic response.  Click Here for this week’s update.
  • Raise the Age NY put out a call for help in urging NY Governor Cuomo and NYC Mayor de Blasio to act quickly to reduce the risks to young people and families posed by the COVID-19 pandemic.  Learn more and spread the word by using their social media toolkit.
In the past few weeks, I’ve felt like the world is going crazy and tilting off its axis.  Then I think about the vital role we play in the lives of our patients and families as we show up each day to care for children, all of whom – either directly or indirectly – have been impacted by this virus.  It’s a quick way to rejuvenate yourself before the next encyclopedia of regulations/policies/procedures arrives in your inbox.
As always, if there is anything more the Chapter could be doing to help pediatricians in this demanding time, please do not hesitate to reach out to us.
Sincerely,
Shetal Shah, MD, FAAP
President, NYS AAP – Chapter 2