Pediatric Care in the Time - PowerPoint Presentation

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Pediatric Care in the Time of COVID-19: The Knowns and Unknowns

Emma Mohr, MD PhD

Division of Pediatric Infectious Diseases

University of Wisconsin-Madison

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Outline and GoalsSpectrum

of symptoms of COVID-19

Transmission

Management

of COVID-19

Epidemiology

Infection control in pediatric

settings

*All related to pediatrics!

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Case presentation5 week old infant, presents to ED with temperature of 100.5⁰F2 week history of congestion, increased fussiness that day

Exam:

A

ctive with normal appearance, comfortable work of breathing, normal breath sounds, TMs normal, no rhinorrhea

Labs: WBC 4.6, 31% PMNs, 40%

lymphs UA: negative LE and nitrites, 0-2 WBC CSF: glucose 56, protein 37, nucleated cells 7, RBC 18Given ceftriaxone dose and admitted to hospitalist service

100.5

ºF

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Case presentationCoronavirus 2019 PCR test positiveBlood, CSF and urine cultures with no growthStable respiratory status, some increased stool outputBreastfeeding well

Discharged home the next day

Isolation recommendations for all household members for 14 days

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SymptomsMilder symptoms than adultsFever (33-100%)Cough (28-100%)Rhinorrhea/sneezing (6-20%)

Sore throat (5-40%)

Headache/dizziness (10%)

Diarrhea (10-15%)

Dyspnea/tachypnea (0-17%)

Skin manifestations (?)(Choi, Kim et al. 2020)

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TransmissionPerson to person by respiratory droplets and contact

Incubation period: 2-14 days

RNA detected from nasopharyngeal/throat swabs 4-48 hours after symptom onset

RNA present in stool from 3 to >30 days after illness onset

Most children infected from family members

Limited evidence because schools are not in session(Cai, Xu et al. 2020); (Su, Ma et al. 2020); https

://www.cdc.gov/coronavirus/2019-ncov/downloads/stop-the-spread-of-germs.pdf

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Clinical CourseAsymptomatic (0-13%)Acute URI (20-65%)Mild pneumonia (27-80%)

Severe pneumonia (0-16%)

Critical case (0-1.5%)

Co-infection with other respiratory viruses common (up to 40%)

(Xia, Shao et al. 2020)(Choi, Kim et al. 2020)

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Clinical OutcomesTypical:Fever 1-2 days, range up to 8 daysComplete blood counts mostly normalCRP normal or temporarily increased

Symptoms mostly resolve in a

week

Less common:

Critically ill patients with respiratory disease typically have underlying medical condition: congenital heart disease, chronic lung disease, immunosuppression

Late manifestation: Pediatric multisystem inflammatory syndrome (?)(Choi, Kim et al. 2020); (Team. 2020); https

://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID19-symptoms.pdf

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COVID Toes/ChilblainsIncreased incidence of chilblains: erythematous to purpuric macules and violaceous swellings located on the toes, feet, fingers and hands

Mild respiratory symptoms reported in 50% of patients about 14 days prior to skin manifestations

Coagulation studies normal

All resolved without intervention

1 of 19 cases in a series was SARS-CoV-2 PCR positive

Serology unknown

(Andina, Noguera-Morel et al. 2020)

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Increasing number of pediatric cases with “persistent fever, inflammation, organ dysfunction, and other specific clinical and laboratory features not attributable to other infections” noted in the UK

Pediatric multisystem inflammatory

syndrome (PIMS)

Cases documented in East coast cities, some in Midwest and South

No cases recorded on the West coast, Japan or Korea

https://discoveries.childrenshospital.org/covid-19-inflammatory-syndrome-children/

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Pediatric multisystem inflammatory syndromeCase definition:Persistent fever, inflammation, organ dysfunction (may fulfill full or partial criteria for Kawasaki disease)

Exclusion of other microbial causes including bacterial sepsis, staph/strep toxic shock syndrome, enterovirus myocarditis.

SARS-CoV-2 PCR testing may be positive or negative. Antibody testing sometimes but not always positive

Outcomes: some death documented, mortality rate unclear

https://discoveries.childrenshospital.org/covid-19-inflammatory-syndrome-children/

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Pediatric multisystem inflammatory syndromeRetrospective cohort study from Italy

Group

2015-2020 (n=19)

Group after February

2020 (n=10)

COVID-19 testingNA8/10 with IgM or IgG positive; 2/10 with positive PCRDisease incidence

0.3/month10/monthMean age3 years7.5 yearsAbnormal echocardiography2/196/10Kawasaki disease shock

syndrome0/195/10Macrophage activation syndrome0/195/10Need for adjunctive steroid treatment

3/19

8/10Response to treatment19/19

10/10(Verdoni,

Mazza et al. 2020)

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Clinical course: neonatal

Incidence of neonatal infection: 10%

3 of 33 neonates born to COVID-19 positive females had positive nasopharyngeal PCRs

Clinical course

M

ild in 2/3 infants: fever, lethargy, pneumonia, recovered within a week

Severe in 1/3 infants: complicated by prematurity, respiratory distress and sepsis

(Zeng, Xia et al. 2020)

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Testing RecommendationsAll inpatients are tested with PCR test upon admissionOutpatient testing done at physician discretion

Antibody testing available

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Management: clinicalSupportive care recommendedNo approved antiviral medicationsPlasma therapy trial for adults initiated

Pediatric guidelines are being developed

Supportive care is the recommended first line

therapy

Remdesivir

or convalescent plasma may be considered

https://news.wisc.edu/; (Chiotos, Hayes et al. 2020)

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Management: children with asthmaUncontrolled asthma is a risk factor for COVID-19 severe diseaseGoal is to control asthma per usual recommendations

No recommendation to stop taking or avoid prescribing oral steroids for an acute asthma attack

Inhaled steroids, antihistamines, bronchodilators and leukotriene receptor antagonists are not hypothesized to increase the risk of COVID-19

(Brough, Kalayci et al. 2020)

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We need better pediatric data!Division of Peds

ID is actively entering patient data into national pediatric registry

Please contact

Emma Mohr by Epic

Inbasket

if you know of a COVID19 positive pediatric patient

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703 patients reported88 participating institutions662 General peds, 2 transplant, 39 immunocompromised

Median age at diagnosis: 12

https://www.pedscovid19registry.com/

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General

pediatrics (n=662)

Immunocompromised (n=39)

Hospitalized in first 7 days of diagnosis

23%

49%

ICU admission within 7 days of diagnosis7%13%

Alive at day 7 post-diagnosis99.5%100%https://www.pedscovid19registry.com/

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Infection Control Delivery room and newborn nurserySchool and childcare centers

Open childcare programs

Breastfeeding

Masks

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Delivery Room Management

Delivery room management

Responding clinicians should use airborne, droplet and contact precautions-level PPE, given the increased likelihood of infant aerosols

Maternal and newborn separation

Temporary separation minimizes the risk of postnatal infant infection from maternal respiratory secretions.

Separation benefits may be higher in mothers with more serious illness.

Discuss with mother prior to delivery.

https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf

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Newborn Nursery ManagementNewborn admission after maternal separationBathe ASAP to remove virus on skin surfaces

Use airborne isolation if requiring aerosol generating procedures

Alternative well newborn care

If not able to separate mother and infant, mother should comply with strict preventative precautions including use of mask, breast and hand hygiene.

Newborn viral testing

PCR test at 24 hours of age, repeat at ~48 hours of age. https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf

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Newborn discharge recommendationsPositive infantDischarge home on a case by case basis with appropriate precautions and plan for frequent outpatient follow-up through 14 days after birth.

Caretakers should use masks, gloves and hand hygiene.

Negative infant

Discharge home to care of a non-infected caregiver

Or mother should use mask and hand hygiene until she has been afebrile for 72 hours AND at least 7 days have passed since symptoms first appeared OR two negative SARS-CoV-2 PCR tests

https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf

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NICU ManagementMaternal visitation for infants requiring ongoing hospital care:Mothers should have resolution of fever for 72 hours AND improvement in respiratory symptoms AND negative SARS-CoV-2

PCR tests

https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf

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When?

How?

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Key questionsDoes a low percentage of infected kids reflect lower susceptibility to infection or higher asymptomatic rate?Unclear how children contribute to transmission of COVID-19Unclear how common late manifestations of disease, like PIMS, are in children

(Viner and Whittaker 2020)

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Notify health officialsDismiss students and recommend social distancingMaintain confidentiality of the affected student/staff memberDisinfect areas used by the individuals with COVID-19

Make decision about extending dismissal with local health officials

Ensure continuity of education, meal programs, essential medical and social services

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html

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Schools are not expected to screen students or staff to identify cases of COVID-19Prepare everyday prevention actions for students and staffHandwashing posters available at CDCShare absenteeism information with health officialsDiscourage the use of perfect attendance awards and incentives

Clean frequently touched surfaces

Keyboards, desks etc.

Sick students and staff stay home

Consider alternative school nurse locations: for respiratory illness & other injuries

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html

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Continue using strategies when there was no community transmissionImplement additional mitigation strategiesCancel large gatheringsModify classes with close contact (PE, music)Increase space between desks

Stagger arrival/dismissal times

Limit nonessential visitors (i.e. school volunteers)

Limit cross-school transfer

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html

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Other school considerationsAnnual School Health RequirementsAllow extensions to required annual paperworkPrioritize immunizationsStudents with Disabilities

Schools can expect a backlog of evaluations, need to prioritize new referrals over re-evaluations

High risk populations

Consider continuing home learning for mechanical ventilation-dependent children or children with tracheostomies

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/covid-19-planning-considerations-return-to-in-person-education-in-schools/

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Childcare Centers

How?

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Childcare Center RecommendationsKeep each group of children in a separate room

Space out cribs/mats as much as possible. Or head to toe.

Stagger playground times

Consider curbside or staggered drop off and pick up of children

Administrative staff telework from home

Don’t use toys that cannot be cleaned and sanitizedAvoid family-style meals and common serving utensilsDaily health checks:Screen children upon arrival for fever (any approach)Other signs of illness

Children’s books are not considered high risk for transmission and do not need additional cleaninghttps://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-childcare.html

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Masks for childrenRecommend children >2 years old wear cloth face masks in places where they may not be able to avoid staying 6 feet away from others

Doctor, pharmacy, grocery store

No need to wear mask when playing outside (if distancing) or at home

Younger kids who don’t understand physical distancing should stay home

https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Cloth-Face-Coverings-for-Children-During-COVID-19.aspx

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Breastfeeding and COVID-19No evidence that COVID-19 is transmitted via breastmilkInfected or under investigation women should express breastmilk and have a healthy caregiver feed the baby

Clean pump parts between use

If there is no way to physically distance from baby, mom should wear a mask and wash hands before handling baby

https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Breastfeeding-During-COVID-19.aspx

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ConclusionsPediatric symptoms are milder than adults

Patients with underlying medical conditions are at higher risk

Be aware of possible late manifestations

Supportive care is recommended

Notify pediatric ID of all COVID positive pediatric patients for national registry

Work with local health officials in opening up schools and childcare centers