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Town hall takeaways: Pediatricians discuss lasting health impacts of COVID-19 on children

March 23, 2021

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Multisystem inflammatory syndrome in children (MIS-C), myalgic encephalitis/chronic fatigue syndrome (MECFS), rheumatologic challenges and neuropsychiatric problems are among COVID-19-related clinical issues observed by experts who spoke at a virtual AAP town hall meeting.

Without a clinical roadmap, pediatricians have been charting new territory to navigate these and other COVID-19-related illnesses and post-infection symptoms, said AAP Chief Population Health Officer Anne R. Edwards, M.D., FAAP, who hosted the town hall.

Peter C. Rowe, M.D., FAAP, director and professor of pediatrics at Children’s Center Chronic Fatigue Clinic/Johns Hopkins, is following a large cohort of adolescents and young adults who have developed long-term MECFS after COVID-19 infection. MECFS can cause substantial impairment in previously tolerated activities and profound fatigue, unrefreshing sleep and post-exertional malaise after activity, according to the Institute of Medicine. Dr. Rowe said patients also may experience orthostatic intolerance and cognitive problems that emerge suddenly and resemble attention-deficit/hyperactivity disorder (inattentive type).

“These people can’t even sit up … they can’t stand for two minutes to microwave their food. It’s really quite extraordinary. They have terrible brain fog. … they’re fatigued from the beginning,” he said. “This orthostatic intolerance is not something that you can blame on deconditioning and inactivity.”

Telemedicine has been a valuable resource for these patients to access care because the physical demands of coming in for a clinic visit could cause a flareup of MECFS symptoms, he said.

Edward E. Conway Jr., M.D., M.S., FCCM, FAAP, past chair of the AAP Section on Critical Care Executive Committee, said while much has been learned about MIS-C over the past year, it still perplexes doctors.

He has seen patients in the intensive care unit with a more severe “adult” version of multisystem inflammatory syndrome (MIS-A). He described one patient who started out with an intracranial bleed, developed acute respiratory distress syndrome, got better and then developed nephrotic syndrome and vasculitis and has been put on steroids.

“And yet she’s sitting there talking to us eating pizza,” he said. “Every day, we learn something, and every day there’s another confounding case … it’s an unusual disease, very humbling.”

Long-term cardiac issues emerged as concerns early in the pandemic, and doctors are now observing patients with MIS-C, MIS-A and long COVID who require ongoing care for other issues as well, said Sandy D. Hong, M.D., FAAP, chair of the AAP Section on Rheumatology Executive Committee.

For example, children with neurologic symptoms will need to be followed regularly with neuropsychiatric testing over the next several years, and MIS-C will be part of the differential diagnosis for Kawasaki disease, she said.

Dr. Hong is eager to see how COVID-19 vaccines will impact the number of patients with MIS-C. However, once children can be vaccinated, pediatricians will need to pay attention to the types of antibody tests used for patients with Kawasaki-like illness so they can differentiate vaccine antibodies from antibodies due to COVID-19 illness, she said.

Panelists discussed other clinical pearls, including:

  • COVID toes and fingers. “We definitely see COVID toes and fingers post COVID, and it doesn't necessarily mean that the patients are going to have a long-term vasculitis,” Dr. Hong said. Unlike frostbite, COVID toes look more like pernio and have soft tissue swelling, blistering and ulcers under the skin that show up at different stages.
  • Some new variants “look like they can result in higher viral loads, and therefore infect more cells,” which could make them more transmissible, said Yvonne A. Maldonado, M.D., FAAP, chair of the AAP Committee on Infectious Diseases. So far, only the B117 variant has been shown in retrospective analysis to be associated with increased morbidity and mortality.
  • Vaccine refusals are occurring at the same rate among health care workers as the general population. “When you ask them why they don’t want to be vaccinated, they say they don’t trust the government, the vaccine was made too quickly,” Dr. Maldonado said.
  • The vaccines were tested for efficacy against disease and not against asymptomatic infection, Dr. Maldonado said. “This is why these vaccines need to be distributed widely and uptake needs to be high.”
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