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Subspecialists rise to challenge during COVID-19 pandemic

September 22, 2020
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Health care workers at Children’s National Hospital prepare for patient care in a COVID-19 testing tent outside the hospital’s emergency department

 

Editor’s note:This is the second of two articles in which members of AAP sections reflect on the challenges their specialty has faced during the COVID-19 pandemic and how it has changed the way they practice. Read the first article at https://bit.ly/3bMFtta.

Rheumatology: Social distancing and community building
Dr. HongPediatric rheumatology has experienced unprecedented collaboration during the pandemic as the widespread use of online platforms has opened the door to virtual meetings across institutions, specialties and international borders. This has affected not only patient care related to COVID-19 but all patient care.

In April, news from Italy and the United Kingdom (U.K.) indicated the appearance of a hyper-inflammatory syndrome in children associated with COVID-19. I joined the Pediatric Intensive Care-COVID-19 International Collaborative via Zoom. This group of over 500 pediatric specialists, including intensivists, rheumatologists and cardiologists, across the world is collecting data about COVID-19 treatment and outcomes. By early May, we were able to learn about the presentations and treatments used for what is now referred to as multisystem inflammatory syndrome in children (MIS-C). This was several weeks prior to the first publications from the U.K.

In June, the Childhood Arthritis and Rheumatology Research Alliance, which includes most of the pediatric rheumatologists in the U.S. and Canada, had its first ever online Zoom meeting open to all members to discuss MIS-C. These international collaborations and sharing of data were essential for information that helped me participate in the formation of the AAP interim guidance on MIS-C (https://bit.ly/3lveqY2).

Prior to the COVID-19 pandemic, I had never used Webex, Zoom or practiced telehealth. On my first day using video-health, I had a new patient who presented with bone marrow failure and a newly discovered heterozygous adenosine deaminase 2 (ADA2) mutation. Patients with ADA2 deficiency are at risk of stroke if not treated appropriately. Within weeks, I met via Zoom with his referring hematologist from another institution and an expert on ADA2 deficiency from the National Institutes of Health to discuss his case and his care.

The COVID-19 pandemic has propelled pediatric rheumatologists to leverage technology to enhance the speed at which we share data and form international collaborations and has opened avenues of patient-to-physician and physician-to-physician communication in ways that were not common in the pre-pandemic era. We are faster, more open and grateful to be part of a community.

Sandy D. Hong, M.D., FAAP,

chair of the AAP Section on Rheumatology Executive Committee

Critical care: Finding joy in caring for adults

Dr. MackIn March, pediatric intensivists and ethicists, along with other colleagues, began discussing scarce resource allocation in the context of a pandemic. The concepts we’d studied and tabletop exercises we’d performed in epidemiology and ethics courses were becoming more tangible. We imagined scenarios where ventilators or perhaps dialysis machines were in short supply.

Soon thereafter, we would learn that the surge of adults infected with COVID-19 would result in shortages of adult intensive care unit beds, respiratory therapists, nurses, physicians and many other members of the multidisciplinary care team. Pediatric intensive care units (PICUs) around the globe, along with the new Shawn Jenkins Children’s Hospital in Charleston, S.C., saw a need in the adult hospital and capacity in the children’s hospital.

Dual trained intensivists published their recommendations on anticipated educational, supply and equipment needs (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331597/). Locally, we created criteria for adult transfer or admission, but our criteria yielded very few patients, so we opened up to match the need. We spoke with other PICUs around the world about lessons learned. The learning curve was tremendous, as was the joy and fulfillment that came from caring for these incredible adult humans with careers, families and tremendous lived experiences.

We also gained an appreciation for our own health, as it was no longer easy to distance ourselves from the virus’ wrath.

Our adult colleagues have been gracious and patient, and our teams have appreciated the child in each of us. The humanity in these experiences is sealed in the hearts of our pediatric critical care teams forever.

Elizabeth Mack, M.D., M.S., FAAP,

chair of the AAP Section on Critical Care

Infectious diseases: Multidisciplinary teams blossom

Dr. BisharaInfectious diseases do not honor man-made divisions between specialties and subspecialties, and SARS-CoV-2 is no different. This virus has been the most deceiving and disrespectful opponent we have ever known. We could not possibly expect to defeat this enemy by remaining as separate individuals within our respective specialties.

With one mind focused on the same goal, barriers initially built and upheld for years out of mass insecurity to maintain the vertical hierarchy within medicine came crumbling down. Sharp lines drawn between subspecialties faded away.

Multidisciplinary teams of both trainees and experts naturally blossomed. Roles and their corresponding limitations were identified, allowing for the development of diagnostic and therapeutic algorithms. In discovering the necessity of each part in our collective functioning, we uncovered the value in ourselves. The driving energy was no longer self-preservation to confirm an identity distinct from others, but rather preservation of the whole to confirm an identity intricately united as one.

With this novel pandemic, we watched our pediatric infectious diseases (ID), infection control, epidemiology and lab teams join forces. We developed algorithms, implemented multidisciplinary COVID-19 huddles and arranged web conferences with other area hospitals to share knowledge and make treatment protocols in real time, in response to what was being seen clinically. We witnessed a cool, collected demeanor and readiness to rise to an unprecedented challenge that carried us through when SARS-CoV2 reached our shores.

Dr. DanielThere is still much to be learned about COVID-19. As pediatric ID fellows in the nation’s capital, under the guidance of incredible mentors and alongside impressive colleagues, we plan to rise to the challenge.

Adversity has the potential to destroy or to allow us to rise to overcome the problem. While challenging, it has been an honor to play even the smallest role in this force that has evolved to defend and protect one another from our most unwelcome enemy.

Amy Bishara, D.O., and Jency Daniel, M.D.

pediatric infectious diseases fellows and members of the AAP Section on Infectious Diseases

 

Developmental and behavioral pediatrics: Returning to our roots

Dr. SchonwaldDevelopmental-behavioral pediatricians (DBPs) thought, “We have to see our patients in person!” Then overnight, we went remote. We adapted and found we’re well-suited to operate in the setting of a pandemic. We’ve shifted much of our practice to supporting families facing uncertainty.

Managing ambiguity is the superpower of DBPs. We’re accustomed to developmental changes, varied symptoms across settings and evolving diagnostic categories.

To diagnose autism, we assess facial expression during play and conversation. Since we can’t play with very young children mask-free, we now rely more on history and observation. None of the remote or “no-touch” diagnostic testing options are yet validated, but the bar isn’t lowered; the priority is to do no harm. Delaying a diagnosis when treatment is most effective would confer harm.

For children and teens with attention-deficit/hyperactivity disorder, we now focus on at-home behaviors. Many parents observe how hard learning is or how short their child’s attention span is. We use digital measures to diagnose learning and cognitive disorders, typically tools already validated for remote use (https://iopc.squarespace.com/teleneuropsychology-research). Recommendations now include supporting students during remote education.

We’ve shifted how we think about mental health disorders. During social isolation, anxiety, depression and sleep disruption may be medication side effects, co-morbid disorders and/or results of pandemic-related upheavals. Children are at increased risk for abuse; family stress is high. We’ve returned to our professional roots, thinking about each child’s strengths, weaknesses and function within an eco-bio-developmental context. The psychosocial stressors of their ecology have become a focus: How can we support a child and family in this moment in history?

Telehealth is a new window into family life. We see more family dynamics and watch children function in the most comfortable setting. As a field, we must develop new ways to diagnose/monitor accurately, without the regularity of school and office materials, but (payment allowing) I suspect telehealth will be a long-lasting part of DBP care. 

 Alison D. Schonwald, M.D., FAAP,

member of the AAP Section on Developmental and Behavioral Pediatrics

Endocrinology: Telemedicine a success, but access to medications a concern
Dr. BruggemanPediatric endocrinologists have adopted innovative techniques to care for our patients in the midst of COVID-19, including the widespread use of telemedicine.

As a cognitive specialty, many of our visits are well-suited to the telemedicine model. Pediatric endocrinologists already provide a substantial amount of care remotely, from continuous glucose monitoring interpretation in between diabetes visits to adjusting levothyroxine doses over the phone based on interim lab results.

Our division at the University of Florida adapted remarkably to the pandemic by increasing our telemedicine visits 100-fold; we actually had more overall visits with our patients through a combined in-person and telemedicine model than at the same point in 2019. A combined model has allowed us to provide comprehensive, safe care for our patients. We will need to work to ensure that support and funding for access to this valuable resource continues to be available. Research assessing the use of at-home HbA1c kits and other innovations will make telemedicine even more effective within our specialty.

While telemedicine has sustained access to office care, pediatric endocrinologists continue to worry about the impact of COVID-19 on patients’ access to health insurance and vital medications. Prior to the pandemic, families of children with diabetes already spent three times as much on health care than those without diabetes due to the exorbitant cost of insulin and diabetes supplies. Now, millions more Americans are without health insurance, and the list price of analogue insulins continues to be hundreds of dollars per prescription. A recent study by the T1D Exchange showed that nearly one-third of patients with type 1 diabetes experienced diabetic ketoacidosis after infection with COVID-19 (Ebekozien OA, et al. Diabetes Care. 2020;43:e83-e85, https://doi.org/10.2337/dc20-1088). Without intervention, additional adverse outcomes could result from lack of access to health insurance, medications and supplies.

 Brittany Bruggeman, M.D., FAAP,

fellowship trainee member of the AAP Section on Endocrinology Executive Committee

Hospital medicine: Changes in care coordination may be everlasting

Dr. MagyarPediatric hospital medicine (PHM) has faced some interesting challenges due to the pandemic, one of which is how best to coordinate care of the hospitalized patient while working under the uncertainty of COVID-19 testing and diagnosis.

We have seen several patients with multisystem inflammatory syndrome in children (MIS-C) whose treatment requires the assistance of several subspecialty colleagues. While ideal for all involved to round on these patients, this approach also needs to be balanced with concerns about preventing viral spread and minimizing exposure.

Subsequently, hospitalists have helped lead daily rounds on our MIS-C patients where pertinent specialists utilize teleconsults for a group discussion over a secure line. This modality empowers the care team to share patient updates, including lab results and physical exam findings, while the team collaboratively discusses next steps in treatment. This has improved workflow as it provides answers from consultants relatively early in the day while maintaining a unified approach to patient care — something that can be difficult when multiple providers are involved and seeing the same patient at varying times. In addition, when we conduct family-centered rounding, we have a more definitive plan of care, which parents appreciate.

Another step in care coordination has been ensuring our patients continue to have good follow-up after discharge. Due to the pandemic, families remain cautious about travel outside their home, which may impact seeing their primary care provider. By utilizing our hospital’s telehealth structure, we can follow up on outstanding clinical issues and smooth discharge planning. This practice change has benefited many patients and their families, not just the ones with COVID-19.

Overall, PHM has adapted many of its traditional practices due to the pandemic, some of which may be everlasting.

 Matt Magyar, M.D., FAAP,

candidate member of the AAP Section on Hospital Medicine

Neurology: Pioneering new aspects to care

Dr. LotzeAs a child neurologist at Texas Children’s Hospital, telemedicine is a silver lining of this pandemic for me and my patients.

Online visits have reduced parents’ and patients’ time away from work and school, provided greater access for families living far from a child neurologist and eliminated transportation difficulties for children with complex medical needs.

This revitalization of “house calls” allows us to better understand how neurological conditions affect patients in their home environment. In addition, most online telemedicine platforms let neurologists share their screen, allowing them to display and discuss an MRI or other lab results as well as guide parents to online resources. Follow-up visits for patients doing well are shorter, allowing us to have more clinic visits or spend time on other academic pursuits. Telemedicine eventually could allow a child neurologist to be “in the office” with the pediatrician and patient having urgent neurological issues for real-time consultation.

As we navigate this new reality, challenges remain. I worry about disadvantaged populations with limited access to the necessary technology, and this will require vigilance and advocacy. In addition, nothing can truly replace the in-person neurological examination, although with a little ingenuity, key components of the exam can be observed. Teaching families how to do parts of the neurological exam, such as briskly tapping the patellar tendon, not only provides part of the exam but also can be a useful way for the patient and parents to better understand how the nervous system works.

While it can be easy to bemoan the tremendous limitations the pandemic has placed on our lives, this is an exciting time for child neurologists to pioneer new aspects of care for the benefit of our patients.

 Timothy Edward Lotze, M.D., FAAP

member of the AAP Section on Neurology Executive Committee

Urgent care: Committed to minimizing risk, testing, caring for acute conditions

Pediatric urgent care (PUC) has stood as a vital and adaptable frontline vehicle to diagnose, treat and contain the spread of COVID-19. The first case of community spread of COVID-19 in the United States was identified in February at a pediatric urgent care. As the pandemic continues, PUC remains committed to the acute care of children for injuries, illnesses and testing.

Some PUCs with multiple locations designated specific sites for patients with respiratory symptoms and others for nonrespiratory complaints. Some PUCs shifted their hours to complement primary care availability and to limit exposure risk for patients with chronic diseases where physical spaces were shared with subspecialty clinics. Many PUCs implemented or increased use of telemedicine to provide a virtual alternative for acute care.

COVID-19 testing became an immediate and important mission for PUCs to document and contain spread of disease. Some PUC systems transformed locations into testing centers, often featuring drive-up services or outdoor tents. PUC-initiated testing centers allowed staff to conserve personal protective equipment and reference labs to consolidate supply chains. Some PUCs partnered with pediatric practices so the PUC could be an extension of care by providing antigen, polymerase chain reaction or antibody testing, allowing primary care practices to stay “clean” and focus on well care.  Some PUCs performed more than 100 tests daily. PUCs capable of laboratory testing screened febrile children for signs of multisystem inflammatory syndrome in children by measuring serum inflammatory markers.

Many PUCs reported increases in injury management and patient acuity. One multistate PUC group reported that compared to previous years, the relative use of X-ray increased by 50% while the percent of patients requiring laceration repair more than quadrupled (from 1.6% to 9.4%). Similarly, the relative number of patients transferred to the emergency department doubled (from 1% to 2.2%).

 AAP Provisional Section on Urgent Care

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