As the nation enters the second year of the COVID-19 pandemic, pediatricians must acknowledge its sustained impact on their patients and themselves, and look for ways to emerge in a new normal, according to AAP experts participating in a virtual town hall on Thursday.
AAP chief population health officer Anne R. Edwards, M.D., FAAP, led the discussion with panelists James H. Duffee, M.D., M.P.H., FAAP, author of AAP policies on child poverty and trauma-informed care; Matthew J. Molloy, M.D., M.P.H., FAAP, clinical fellow in hospital medicine; and Yvonne A. Maldonado, M.D., FAAP, chair of the AAP Committee on Infectious Diseases.
Intersecting economic and public health crises, ethnic and racial reckoning and gender discrimination will prolong the effects of the pandemic, according to the panelists.
“This is, I think, something that's going to last within our community and within our pediatric practices for years, if not even decades,” Dr. Duffee said.
Dr. Maldonado agreed, saying it’s unlikely pediatricians will return to the way things were in the past. “And maybe we shouldn't go back to the old normal; we need a new normal.”
A vaccine could be available for older children (e.g., 12- to 15-year-olds) by summer, Dr. Maldonado said. Meanwhile, infectious diseases experts continue studying the SARS-CoV-2 virus and how variants may shape the months ahead. Virus mutations are normal, but experts do not know whether the virus might mutate itself out of existence or turn into a common cold virus, Dr. Maldonado said.
Some of the variants of concern are in the receptor-binding domain of the spike protein where it attaches to the human host cell H2-receptor. This can increase the virus’ ability to stick to human cells and allow for ribonucleic acid entry into the cell, Dr. Maldonado said.
Antibody to the spike protein seems to protect against disease. However, mutations could escape from neutralizing antibody produced by vaccines or natural immunity. “Those are things that we’re tracking carefully,” she said. “In the end, though, it's really going to be about decreasing transmission, because mutations are driven by replication, replication is driven by transmission and amplifying that virus in additional people. So, (continue) to mask and social distance.”
Personal protective equipment (PPE) has been a pearl in reducing pediatric respiratory disease transmission in the hospital setting, and Dr. Molloy anticipates PPE is here to stay.
However, lower patient volume has led to an unexpected situation for pediatric trainees. Two weeks ago, Dr. Molloy saw an infant with bronchiolitis — his first case this year and the only patient with bronchiolitis seen by the interns on his team.
PPE also poses a barrier between pediatricians and their patients. Smiling at a baby and seeing the baby smile back is lost when PPE is worn. “It's going to take a long time to get back to really true relational health, the focus of primary care,” Dr. Duffee said.
Long-term maladaptation also is emerging, as families experience post-traumatic stress from deaths of family members and ongoing insecurities, Dr. Duffee said. He urged pediatricians to screen patients for toxic stress, which is ameliorated through safe, secure, nurturing relationships.
Dr. Molloy has seen a spike in patients with mental health problems presenting to the emergency department and requiring admission and more families screening positive for food insecurity.
The pandemic also has laid bare pediatricians’ vulnerability to burnout, Dr. Duffee said.
“One of the things we don't learn in medical schools is how to take care of ourselves. But also, another thing we don't particularly learn (are) the skills of leading the treatment team,” Dr. Duffee said. “One of the things we have to do with families is … help them realize the trauma that kids are feeling. And I think with each other, we have to realize the trauma that each other is feeling.”
People are still running on adrenaline, Dr. Maldonado said. But when things calm down, “that's when we're probably going to see a lot of the hidden trauma start to emerge, not just among children but among all of our health care workers. Every sector of this country will start to live that out.”
Panelists suggested ways to ameliorate stress, including regular team check-ins, peer support programs, covering for each another to allow time for continuing education or a sabbatical, and added support for employees caring for young children and older family members.
Team leaders should encourage people to talk about their trauma and can use motivational interviewing and reflective supervision tools to connect with their teams, families and children, Dr. Duffee said.
Most pediatricians have not lived through something as monumental as this pandemic, Dr. Maldonado said. “It’s going to be a tough road ahead, but we've gotten through other bad times before. … We can’t forget and we have to learn from what we’ve experienced.”