Pediatrics

The 2019-2020 flu season is ending, but not without a revised map to reflect the COVID-induced new world order.

[email protected]

The 2019-2020 flu season is ending, but not without a revised map to reflect the COVID-induced new world order.

[email protected]

The 2019-2020 flu season is ending, but not without a revised map to reflect the COVID-induced new world order.

[email protected]

A policy of universal screening of pregnant women for the COVID-19 virus identified a high proportion of women who tested positive and were asymptomatic, based on data from 215 pregnant women in New York City.

Courtesy NIAID-RML

“The obstetrical population presents a unique challenge during this pandemic, since these patients have multiple interactions with the health care system and eventually most are admitted to the hospital for delivery,” wrote Desmond Sutton, MD, and colleagues at Columbia University Irving Medical Center, New York

In a letter published in the New England Journal of Medicine, the researchers reviewed their experiences with 215 pregnant women who delivered infants during March 22–April 4, 2020, at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center. All the women were screened for symptoms of the COVID-19 infection on admission.

Overall, four women (1.9%) had fevers or other symptoms on admission, and all of these women tested positive for the virus that causes COVID-19. The other 211 women were afebrile and asymptomatic at admission, and 210 of them were tested via nasopharyngeal swabs. A total of 29 asymptomatic women (13.7%) tested positive for COVID-19 infection.

“Thus, 29 of the 33 patients who were positive for SARS-CoV-2 at admission (87.9%) had no symptoms of COVID-19 at presentation,” Dr. Sutton and colleagues wrote.

Three of the 29 COVID-19-positive women who were asymptomatic on admission developed fevers before they were discharged from the hospital after a median stay of 2 days. Of these, two received antibiotics for presumed endomyometritis and one patient with presumed COVID-19 infection received supportive care. In addition, one patient who was initially negative developed COVID-19 symptoms after delivery and tested positive 3 days after her initial negative test.

“Our use of universal SARS-CoV-2 testing in all pregnant patients presenting for delivery revealed that at this point in the pandemic in New York City, most of the patients who were positive for SARS-CoV-2 at delivery were asymptomatic,” Dr. Sutton and colleagues said.

Although their numbers may not be generalizable to areas with lower infection rates, they highlight the risk of COVID-19 infection in asymptomatic pregnant women, they noted.

“The potential benefits of a universal testing approach include the ability to use COVID-19 status to determine hospital isolation practices and bed assignments, inform neonatal care, and guide the use of personal protective equipment,” they concluded.
 

Continuing challenges

“What I have seen in our institute is the debate about rapid testing and the inherent problems with false negatives and false positives,” Catherine Cansino, MD, of the University of California, Davis, said in an interview. “I think there is definitely a role for universal testing, especially in areas with high prevalence,” and the New York clinicians have made a strong case.

However, the challenge remains of obtaining quick test results that would still be reliable, as many rapid tests have a false-negative rate of as much as 20%, noted Dr. Cansino, who was not involved in the New York study.

Her institution is using a test with a higher level of accuracy, “but it can take several hours or a day to get the results,” at which point the women may have gone through labor and delivery and been in contact with multiple health care workers who have used personal protective equipment accordingly if they don’t know a patient’s status.

To help guide policies, Dr. Cansino said that outcome data would be useful. “It’s hard to know how outcomes are different, and it would be good to know how transmission rates differ between symptomatic carriers and those who are asymptomatic.”

“As SARS-CoV-2, the virus responsible for COVID-19, continues to spread, pregnant women remain a unique population with required frequent health system contacts and ultimate need for delivery,” Iris Krishna, MD, of the Emory Healthcare Network in Atlanta, said in an interview. “This report in a high prevalence area demonstrated 1 out of 8 asymptomatic pregnant patients presenting for delivery were SARS-CoV-2 positive, illustrating a need for universal screening.

“As this pandemic evolves, we are learning more and more, and it is important to expand our understanding of asymptomatic transmission and the risk this may pose,” said Dr. Krishna, who was not part of the New York study.

“Key benefits to universal screening are the capability for labor and delivery units to implement best hospital practices in their care of mothers and babies, such as admitting positive patients to cohort units,” she noted. Such units would “allow for closer monitoring of mothers and babies, as well as ensuring proper use of personal protective equipment by health care teams” and also would help preserve supplies of personal protective equipment.

Dr. Krishna cited hospital testing capacity as an obvious barrier to universal screening of pregnant women, as well as factors including the need for additional protective equipment to be used during swab collection. Also, “If you get a negative result and there is a strong suspicion for COVID-19 infection, when do you retest?” she asked. “These are key questions or areas of assessment that should be considered before embarking on universal screening for pregnant women.” In addition, some patients may refuse testing out of fear of stigma or separation from their newborn.

“Implementing an ‘opt out’ approach to screening is encouraged, whereby a patient is informed that a test will be included in standard preventive screening, and they may decline the test,” Dr. Krishna said. “Routine, opt-out screening approaches have proven to be highly effective as it removes the stigma associated with testing, fosters earlier diagnosis and treatment, reduces risk of transmission, and has proven to be cost effective. Pregnant women should be reassured that universal screening is beneficial for their care and the care of their newborn baby,” she emphasized.

“Institutions should consider implementing universal screening on labor and delivery as several geographic areas are predicted to reach their peak time of COVID-19 transmission, and it is clear that asymptomatic individuals continue to play a role in its transmission,” Dr. Krishna concluded.

Dr. Sutton and associates had no financial conflicts to disclose. Neither Dr. Cansino nor Dr. Krishna had any financial conflicts to disclose. Dr. Cansino and Dr. Krishna are members of the Ob.Gyn. News Editorial Advisory Board.

SOURCE: Sutton D et al. N Engl J Med. 2020 Apr 13. doi: 10.1056/NEJMc2009316.

A policy of universal screening of pregnant women for the COVID-19 virus identified a high proportion of women who tested positive and were asymptomatic, based on data from 215 pregnant women in New York City.

Courtesy NIAID-RML

“The obstetrical population presents a unique challenge during this pandemic, since these patients have multiple interactions with the health care system and eventually most are admitted to the hospital for delivery,” wrote Desmond Sutton, MD, and colleagues at Columbia University Irving Medical Center, New York

In a letter published in the New England Journal of Medicine, the researchers reviewed their experiences with 215 pregnant women who delivered infants during March 22–April 4, 2020, at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center. All the women were screened for symptoms of the COVID-19 infection on admission.

Overall, four women (1.9%) had fevers or other symptoms on admission, and all of these women tested positive for the virus that causes COVID-19. The other 211 women were afebrile and asymptomatic at admission, and 210 of them were tested via nasopharyngeal swabs. A total of 29 asymptomatic women (13.7%) tested positive for COVID-19 infection.

“Thus, 29 of the 33 patients who were positive for SARS-CoV-2 at admission (87.9%) had no symptoms of COVID-19 at presentation,” Dr. Sutton and colleagues wrote.

Three of the 29 COVID-19-positive women who were asymptomatic on admission developed fevers before they were discharged from the hospital after a median stay of 2 days. Of these, two received antibiotics for presumed endomyometritis and one patient with presumed COVID-19 infection received supportive care. In addition, one patient who was initially negative developed COVID-19 symptoms after delivery and tested positive 3 days after her initial negative test.

“Our use of universal SARS-CoV-2 testing in all pregnant patients presenting for delivery revealed that at this point in the pandemic in New York City, most of the patients who were positive for SARS-CoV-2 at delivery were asymptomatic,” Dr. Sutton and colleagues said.

Although their numbers may not be generalizable to areas with lower infection rates, they highlight the risk of COVID-19 infection in asymptomatic pregnant women, they noted.

“The potential benefits of a universal testing approach include the ability to use COVID-19 status to determine hospital isolation practices and bed assignments, inform neonatal care, and guide the use of personal protective equipment,” they concluded.
 

Continuing challenges

“What I have seen in our institute is the debate about rapid testing and the inherent problems with false negatives and false positives,” Catherine Cansino, MD, of the University of California, Davis, said in an interview. “I think there is definitely a role for universal testing, especially in areas with high prevalence,” and the New York clinicians have made a strong case.

However, the challenge remains of obtaining quick test results that would still be reliable, as many rapid tests have a false-negative rate of as much as 20%, noted Dr. Cansino, who was not involved in the New York study.

Her institution is using a test with a higher level of accuracy, “but it can take several hours or a day to get the results,” at which point the women may have gone through labor and delivery and been in contact with multiple health care workers who have used personal protective equipment accordingly if they don’t know a patient’s status.

To help guide policies, Dr. Cansino said that outcome data would be useful. “It’s hard to know how outcomes are different, and it would be good to know how transmission rates differ between symptomatic carriers and those who are asymptomatic.”

“As SARS-CoV-2, the virus responsible for COVID-19, continues to spread, pregnant women remain a unique population with required frequent health system contacts and ultimate need for delivery,” Iris Krishna, MD, of the Emory Healthcare Network in Atlanta, said in an interview. “This report in a high prevalence area demonstrated 1 out of 8 asymptomatic pregnant patients presenting for delivery were SARS-CoV-2 positive, illustrating a need for universal screening.

“As this pandemic evolves, we are learning more and more, and it is important to expand our understanding of asymptomatic transmission and the risk this may pose,” said Dr. Krishna, who was not part of the New York study.

“Key benefits to universal screening are the capability for labor and delivery units to implement best hospital practices in their care of mothers and babies, such as admitting positive patients to cohort units,” she noted. Such units would “allow for closer monitoring of mothers and babies, as well as ensuring proper use of personal protective equipment by health care teams” and also would help preserve supplies of personal protective equipment.

Dr. Krishna cited hospital testing capacity as an obvious barrier to universal screening of pregnant women, as well as factors including the need for additional protective equipment to be used during swab collection. Also, “If you get a negative result and there is a strong suspicion for COVID-19 infection, when do you retest?” she asked. “These are key questions or areas of assessment that should be considered before embarking on universal screening for pregnant women.” In addition, some patients may refuse testing out of fear of stigma or separation from their newborn.

“Implementing an ‘opt out’ approach to screening is encouraged, whereby a patient is informed that a test will be included in standard preventive screening, and they may decline the test,” Dr. Krishna said. “Routine, opt-out screening approaches have proven to be highly effective as it removes the stigma associated with testing, fosters earlier diagnosis and treatment, reduces risk of transmission, and has proven to be cost effective. Pregnant women should be reassured that universal screening is beneficial for their care and the care of their newborn baby,” she emphasized.

“Institutions should consider implementing universal screening on labor and delivery as several geographic areas are predicted to reach their peak time of COVID-19 transmission, and it is clear that asymptomatic individuals continue to play a role in its transmission,” Dr. Krishna concluded.

Dr. Sutton and associates had no financial conflicts to disclose. Neither Dr. Cansino nor Dr. Krishna had any financial conflicts to disclose. Dr. Cansino and Dr. Krishna are members of the Ob.Gyn. News Editorial Advisory Board.

SOURCE: Sutton D et al. N Engl J Med. 2020 Apr 13. doi: 10.1056/NEJMc2009316.

A policy of universal screening of pregnant women for the COVID-19 virus identified a high proportion of women who tested positive and were asymptomatic, based on data from 215 pregnant women in New York City.

Courtesy NIAID-RML

“The obstetrical population presents a unique challenge during this pandemic, since these patients have multiple interactions with the health care system and eventually most are admitted to the hospital for delivery,” wrote Desmond Sutton, MD, and colleagues at Columbia University Irving Medical Center, New York

In a letter published in the New England Journal of Medicine, the researchers reviewed their experiences with 215 pregnant women who delivered infants during March 22–April 4, 2020, at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center. All the women were screened for symptoms of the COVID-19 infection on admission.

Overall, four women (1.9%) had fevers or other symptoms on admission, and all of these women tested positive for the virus that causes COVID-19. The other 211 women were afebrile and asymptomatic at admission, and 210 of them were tested via nasopharyngeal swabs. A total of 29 asymptomatic women (13.7%) tested positive for COVID-19 infection.

“Thus, 29 of the 33 patients who were positive for SARS-CoV-2 at admission (87.9%) had no symptoms of COVID-19 at presentation,” Dr. Sutton and colleagues wrote.

Three of the 29 COVID-19-positive women who were asymptomatic on admission developed fevers before they were discharged from the hospital after a median stay of 2 days. Of these, two received antibiotics for presumed endomyometritis and one patient with presumed COVID-19 infection received supportive care. In addition, one patient who was initially negative developed COVID-19 symptoms after delivery and tested positive 3 days after her initial negative test.

“Our use of universal SARS-CoV-2 testing in all pregnant patients presenting for delivery revealed that at this point in the pandemic in New York City, most of the patients who were positive for SARS-CoV-2 at delivery were asymptomatic,” Dr. Sutton and colleagues said.

Although their numbers may not be generalizable to areas with lower infection rates, they highlight the risk of COVID-19 infection in asymptomatic pregnant women, they noted.

“The potential benefits of a universal testing approach include the ability to use COVID-19 status to determine hospital isolation practices and bed assignments, inform neonatal care, and guide the use of personal protective equipment,” they concluded.
 

Continuing challenges

“What I have seen in our institute is the debate about rapid testing and the inherent problems with false negatives and false positives,” Catherine Cansino, MD, of the University of California, Davis, said in an interview. “I think there is definitely a role for universal testing, especially in areas with high prevalence,” and the New York clinicians have made a strong case.

However, the challenge remains of obtaining quick test results that would still be reliable, as many rapid tests have a false-negative rate of as much as 20%, noted Dr. Cansino, who was not involved in the New York study.

Her institution is using a test with a higher level of accuracy, “but it can take several hours or a day to get the results,” at which point the women may have gone through labor and delivery and been in contact with multiple health care workers who have used personal protective equipment accordingly if they don’t know a patient’s status.

To help guide policies, Dr. Cansino said that outcome data would be useful. “It’s hard to know how outcomes are different, and it would be good to know how transmission rates differ between symptomatic carriers and those who are asymptomatic.”

“As SARS-CoV-2, the virus responsible for COVID-19, continues to spread, pregnant women remain a unique population with required frequent health system contacts and ultimate need for delivery,” Iris Krishna, MD, of the Emory Healthcare Network in Atlanta, said in an interview. “This report in a high prevalence area demonstrated 1 out of 8 asymptomatic pregnant patients presenting for delivery were SARS-CoV-2 positive, illustrating a need for universal screening.

“As this pandemic evolves, we are learning more and more, and it is important to expand our understanding of asymptomatic transmission and the risk this may pose,” said Dr. Krishna, who was not part of the New York study.

“Key benefits to universal screening are the capability for labor and delivery units to implement best hospital practices in their care of mothers and babies, such as admitting positive patients to cohort units,” she noted. Such units would “allow for closer monitoring of mothers and babies, as well as ensuring proper use of personal protective equipment by health care teams” and also would help preserve supplies of personal protective equipment.

Dr. Krishna cited hospital testing capacity as an obvious barrier to universal screening of pregnant women, as well as factors including the need for additional protective equipment to be used during swab collection. Also, “If you get a negative result and there is a strong suspicion for COVID-19 infection, when do you retest?” she asked. “These are key questions or areas of assessment that should be considered before embarking on universal screening for pregnant women.” In addition, some patients may refuse testing out of fear of stigma or separation from their newborn.

“Implementing an ‘opt out’ approach to screening is encouraged, whereby a patient is informed that a test will be included in standard preventive screening, and they may decline the test,” Dr. Krishna said. “Routine, opt-out screening approaches have proven to be highly effective as it removes the stigma associated with testing, fosters earlier diagnosis and treatment, reduces risk of transmission, and has proven to be cost effective. Pregnant women should be reassured that universal screening is beneficial for their care and the care of their newborn baby,” she emphasized.

“Institutions should consider implementing universal screening on labor and delivery as several geographic areas are predicted to reach their peak time of COVID-19 transmission, and it is clear that asymptomatic individuals continue to play a role in its transmission,” Dr. Krishna concluded.

Dr. Sutton and associates had no financial conflicts to disclose. Neither Dr. Cansino nor Dr. Krishna had any financial conflicts to disclose. Dr. Cansino and Dr. Krishna are members of the Ob.Gyn. News Editorial Advisory Board.

SOURCE: Sutton D et al. N Engl J Med. 2020 Apr 13. doi: 10.1056/NEJMc2009316.

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].

As the COVID-19 pandemic continues, many cancer patients are finding it increasingly difficult to receive the care they need and are facing financial challenges.

Half of the cancer patients and survivors who responded to a recent survey reported changes, delays, or disruptions to the care they were receiving. The survey, with 1,219 respondents, was conducted by the American Cancer Society Cancer Action Network (ACS CAN).

“The circumstances of this virus – from the fact cancer patients are at higher risk of severe complications should they be diagnosed with COVID-19, to the fact many patients are facing serious financial strain caused by the virus’ economic effect – make getting care especially difficult,” Keysha Brooks-Coley, vice president of federal advocacy for ACS CAN, told Medscape Medical News.

Nearly a quarter (24%) of survey respondents reported a delay in care or treatment. The proportion was slightly more (27%) among those currently receiving active treatment.

In addition, 12% (13% in active treatment) stated that not only was their care delayed but that they also have not been told when services would be rescheduled.

As previously reported by Medscape Medical News, many oncology groups have issued new guidelines for cancer care in reaction to the current crisis. These include recommendations to delay cancer treatment in order to avoid exposing cancer patients to the virus.

Half of those in active treatment report disruptions

The survey was initiated by ACS CAN on March 25 and was distributed over a 2-week period. The goal was to gain a better understanding of how COVID-19 was affecting cancer patients and survivors in the United States. Of the 1,219 respondents, half (51%) were cancer patients currently undergoing active treatment.

Among the patients and survivors who were currently in active treatment, 55% reported that there have been changes, delays, or disruptions in their care. The services most frequently affected included in-person provider visits (50%), supportive services (20%), and imaging procedures to monitor tumor growth (20%).

In addition, 8% reported that their treatment, including chemotherapy and immunotherapy, had been affected by the COVID-19 pandemic.

Financial concerns

Almost all of the survey respondents were covered by some type of insurance; 49% had coverage through an employer, 32% were covered by Medicare, 7% had privately purchased insurance, and 4% were covered through Medicaid.

Many cancer patients had already been having difficulty paying for their care, but for a substantial proportion of survey respondents, the COVID-19 pandemic has exacerbated the problem. More than one-third (38%) stated that COVID-19 “has had a notable impact on their financial situation that affects their ability to pay for health care.”

The most common financial problems that were related to access to care include reduced work hours (14%), reduced investment values (11%), having difficulty affording food and supplies because of staying at home to avoid contracting the virus (9%), and becoming unemployed (8%).

A reduction in work hours and job loss were of particular concern to respondents because of the possible effects these would have on their health insurance coverage. Of those who reported that they or a family member living with them had lost a job, 43% had employer-sponsored health insurance. Additionally, 58% of patients or a family member whose working hours had been reduced also had health insurance through their employer

Among the entire cohort, 28% reported that they were worried that the financial impact of COVID-19 would make it difficult to pay for the health care they need as cancer survivors. This concern was highly correlated with income. Almost half (46%) of patients who earned $30,000 or less reported that they were worried, but even in household with incomes over $110,000 per year, 21% were also concerned about the financial impact.

“Now more than ever, patients need to be able to get, keep, and afford health coverage to treat their disease,” commented Brooks-Coley.
 

Taking action

“ACS CAN is working every day to make clear to Congress and the administration the real and immediate challenges cancer patients and survivors face during this pandemic,” said Brooks-Coley.

With nearly 50 other professional and advocacy groups, ACS CAN has sent letters to congressional leadership and the Secretary of the Department of Health & Human Services asking them to make policy changes that would help patients.

The proposed action points include having insurers allow patients to use providers who are out of network if necessary; waiving site-specific precertification and prior authorization for cancer treatment; utilizing shared decision making between patients and providers in deciding whether to use home infusion without pressure from the insurer; allowing patients to obtain 90-day supplies of medication; increasing funding for state Medicaid programs and assistance for those who have lost employee-sponsored coverage; and improving telehealth services.

“We urge Congress and the administration to keep the needs of cancer patients and survivors in mind as they continue to address the public health crisis,” she said.

This article first appeared on Medscape.com.

As the COVID-19 pandemic continues, many cancer patients are finding it increasingly difficult to receive the care they need and are facing financial challenges.

Half of the cancer patients and survivors who responded to a recent survey reported changes, delays, or disruptions to the care they were receiving. The survey, with 1,219 respondents, was conducted by the American Cancer Society Cancer Action Network (ACS CAN).

“The circumstances of this virus – from the fact cancer patients are at higher risk of severe complications should they be diagnosed with COVID-19, to the fact many patients are facing serious financial strain caused by the virus’ economic effect – make getting care especially difficult,” Keysha Brooks-Coley, vice president of federal advocacy for ACS CAN, told Medscape Medical News.

Nearly a quarter (24%) of survey respondents reported a delay in care or treatment. The proportion was slightly more (27%) among those currently receiving active treatment.

In addition, 12% (13% in active treatment) stated that not only was their care delayed but that they also have not been told when services would be rescheduled.

As previously reported by Medscape Medical News, many oncology groups have issued new guidelines for cancer care in reaction to the current crisis. These include recommendations to delay cancer treatment in order to avoid exposing cancer patients to the virus.

Half of those in active treatment report disruptions

The survey was initiated by ACS CAN on March 25 and was distributed over a 2-week period. The goal was to gain a better understanding of how COVID-19 was affecting cancer patients and survivors in the United States. Of the 1,219 respondents, half (51%) were cancer patients currently undergoing active treatment.

Among the patients and survivors who were currently in active treatment, 55% reported that there have been changes, delays, or disruptions in their care. The services most frequently affected included in-person provider visits (50%), supportive services (20%), and imaging procedures to monitor tumor growth (20%).

In addition, 8% reported that their treatment, including chemotherapy and immunotherapy, had been affected by the COVID-19 pandemic.

Financial concerns

Almost all of the survey respondents were covered by some type of insurance; 49% had coverage through an employer, 32% were covered by Medicare, 7% had privately purchased insurance, and 4% were covered through Medicaid.

Many cancer patients had already been having difficulty paying for their care, but for a substantial proportion of survey respondents, the COVID-19 pandemic has exacerbated the problem. More than one-third (38%) stated that COVID-19 “has had a notable impact on their financial situation that affects their ability to pay for health care.”

The most common financial problems that were related to access to care include reduced work hours (14%), reduced investment values (11%), having difficulty affording food and supplies because of staying at home to avoid contracting the virus (9%), and becoming unemployed (8%).

A reduction in work hours and job loss were of particular concern to respondents because of the possible effects these would have on their health insurance coverage. Of those who reported that they or a family member living with them had lost a job, 43% had employer-sponsored health insurance. Additionally, 58% of patients or a family member whose working hours had been reduced also had health insurance through their employer

Among the entire cohort, 28% reported that they were worried that the financial impact of COVID-19 would make it difficult to pay for the health care they need as cancer survivors. This concern was highly correlated with income. Almost half (46%) of patients who earned $30,000 or less reported that they were worried, but even in household with incomes over $110,000 per year, 21% were also concerned about the financial impact.

“Now more than ever, patients need to be able to get, keep, and afford health coverage to treat their disease,” commented Brooks-Coley.
 

Taking action

“ACS CAN is working every day to make clear to Congress and the administration the real and immediate challenges cancer patients and survivors face during this pandemic,” said Brooks-Coley.

With nearly 50 other professional and advocacy groups, ACS CAN has sent letters to congressional leadership and the Secretary of the Department of Health & Human Services asking them to make policy changes that would help patients.

The proposed action points include having insurers allow patients to use providers who are out of network if necessary; waiving site-specific precertification and prior authorization for cancer treatment; utilizing shared decision making between patients and providers in deciding whether to use home infusion without pressure from the insurer; allowing patients to obtain 90-day supplies of medication; increasing funding for state Medicaid programs and assistance for those who have lost employee-sponsored coverage; and improving telehealth services.

“We urge Congress and the administration to keep the needs of cancer patients and survivors in mind as they continue to address the public health crisis,” she said.

This article first appeared on Medscape.com.

As the COVID-19 pandemic continues, many cancer patients are finding it increasingly difficult to receive the care they need and are facing financial challenges.

Half of the cancer patients and survivors who responded to a recent survey reported changes, delays, or disruptions to the care they were receiving. The survey, with 1,219 respondents, was conducted by the American Cancer Society Cancer Action Network (ACS CAN).

“The circumstances of this virus – from the fact cancer patients are at higher risk of severe complications should they be diagnosed with COVID-19, to the fact many patients are facing serious financial strain caused by the virus’ economic effect – make getting care especially difficult,” Keysha Brooks-Coley, vice president of federal advocacy for ACS CAN, told Medscape Medical News.

Nearly a quarter (24%) of survey respondents reported a delay in care or treatment. The proportion was slightly more (27%) among those currently receiving active treatment.

In addition, 12% (13% in active treatment) stated that not only was their care delayed but that they also have not been told when services would be rescheduled.

As previously reported by Medscape Medical News, many oncology groups have issued new guidelines for cancer care in reaction to the current crisis. These include recommendations to delay cancer treatment in order to avoid exposing cancer patients to the virus.

Half of those in active treatment report disruptions

The survey was initiated by ACS CAN on March 25 and was distributed over a 2-week period. The goal was to gain a better understanding of how COVID-19 was affecting cancer patients and survivors in the United States. Of the 1,219 respondents, half (51%) were cancer patients currently undergoing active treatment.

Among the patients and survivors who were currently in active treatment, 55% reported that there have been changes, delays, or disruptions in their care. The services most frequently affected included in-person provider visits (50%), supportive services (20%), and imaging procedures to monitor tumor growth (20%).

In addition, 8% reported that their treatment, including chemotherapy and immunotherapy, had been affected by the COVID-19 pandemic.

Financial concerns

Almost all of the survey respondents were covered by some type of insurance; 49% had coverage through an employer, 32% were covered by Medicare, 7% had privately purchased insurance, and 4% were covered through Medicaid.

Many cancer patients had already been having difficulty paying for their care, but for a substantial proportion of survey respondents, the COVID-19 pandemic has exacerbated the problem. More than one-third (38%) stated that COVID-19 “has had a notable impact on their financial situation that affects their ability to pay for health care.”

The most common financial problems that were related to access to care include reduced work hours (14%), reduced investment values (11%), having difficulty affording food and supplies because of staying at home to avoid contracting the virus (9%), and becoming unemployed (8%).

A reduction in work hours and job loss were of particular concern to respondents because of the possible effects these would have on their health insurance coverage. Of those who reported that they or a family member living with them had lost a job, 43% had employer-sponsored health insurance. Additionally, 58% of patients or a family member whose working hours had been reduced also had health insurance through their employer

Among the entire cohort, 28% reported that they were worried that the financial impact of COVID-19 would make it difficult to pay for the health care they need as cancer survivors. This concern was highly correlated with income. Almost half (46%) of patients who earned $30,000 or less reported that they were worried, but even in household with incomes over $110,000 per year, 21% were also concerned about the financial impact.

“Now more than ever, patients need to be able to get, keep, and afford health coverage to treat their disease,” commented Brooks-Coley.
 

Taking action

“ACS CAN is working every day to make clear to Congress and the administration the real and immediate challenges cancer patients and survivors face during this pandemic,” said Brooks-Coley.

With nearly 50 other professional and advocacy groups, ACS CAN has sent letters to congressional leadership and the Secretary of the Department of Health & Human Services asking them to make policy changes that would help patients.

The proposed action points include having insurers allow patients to use providers who are out of network if necessary; waiving site-specific precertification and prior authorization for cancer treatment; utilizing shared decision making between patients and providers in deciding whether to use home infusion without pressure from the insurer; allowing patients to obtain 90-day supplies of medication; increasing funding for state Medicaid programs and assistance for those who have lost employee-sponsored coverage; and improving telehealth services.

“We urge Congress and the administration to keep the needs of cancer patients and survivors in mind as they continue to address the public health crisis,” she said.

This article first appeared on Medscape.com.

To the Editor:

A 3-year-old boy with a history of tuberous sclerosis presented to our clinic for evaluation of bumps on the second and third fingers of the left hand. Physical examination revealed firm rubbery nodules on the palmar third metacarpophalangeal joint extending to the palm and the lateral aspect of the distal third dorsal finger. There also was asymmetric overgrowth of the left second and third digits consistent with bony segmental overgrowth (Figure).

Tuberous sclerosis and overgrowth syndromes including Proteus syndrome have mutations that share a common pathway, namely the PI3K/AKT/mTOR (phosphoinositide 3-kinase/alpha serine/threonine-protein kinase/mammalian target of rapamycin) pathway.¹ The mutations in tuberous sclerosis involve the loss of TSC1 (TSC complex subunit 1) on chromosome 9 or TSC2 (TSC complex subunit 2) on chromosome 16.² The protein products of these genes, hamartin and tuberin, act together as a tumor suppressor complex.³ The inheritance pattern of tuberous sclerosis is autosomal dominant, though two-thirds of cases are due to de novo germline mutations.⁴ The second copy of the gene must be lost spontaneously in any particular cell for the deleterious effects of the disease to manifest. The mutation in overgrowth syndromes including Proteus syndrome involves the activation of AKT1 (AKT serine/threonine kinase 1) on chromosome 14. This mutation occurs in somatic cells as opposed to germ cells, as in tuberous sclerosis. This difference accounts for the mosaic expression of segmental overgrowth syndromes. This concept has been demonstrated in overgrowth syndromes such as Proteus syndrome, with cells from unaffected areas having different genetic makeup than those from affected tissues.⁵ These mutations, though different, result in the downstream effects of unchecked messenger RNA translation and dysregulated cellular growth.

In our patient, we hypothesized that a small proportion of his postfertilization somatic cells underwent a second de novo mutation in the AKT1 pathway, resulting in the bony overgrowth seen on the left hand. We suspected that this second mutation could be an activation of AKT1, the mutation seen in Proteus syndrome. Sequencing of the tissue may be performed in the future, especially if segmental overgrowth continues and necessitates therapy.

To the Editor:

A 3-year-old boy with a history of tuberous sclerosis presented to our clinic for evaluation of bumps on the second and third fingers of the left hand. Physical examination revealed firm rubbery nodules on the palmar third metacarpophalangeal joint extending to the palm and the lateral aspect of the distal third dorsal finger. There also was asymmetric overgrowth of the left second and third digits consistent with bony segmental overgrowth (Figure).

Tuberous sclerosis and overgrowth syndromes including Proteus syndrome have mutations that share a common pathway, namely the PI3K/AKT/mTOR (phosphoinositide 3-kinase/alpha serine/threonine-protein kinase/mammalian target of rapamycin) pathway.¹ The mutations in tuberous sclerosis involve the loss of TSC1 (TSC complex subunit 1) on chromosome 9 or TSC2 (TSC complex subunit 2) on chromosome 16.² The protein products of these genes, hamartin and tuberin, act together as a tumor suppressor complex.³ The inheritance pattern of tuberous sclerosis is autosomal dominant, though two-thirds of cases are due to de novo germline mutations.⁴ The second copy of the gene must be lost spontaneously in any particular cell for the deleterious effects of the disease to manifest. The mutation in overgrowth syndromes including Proteus syndrome involves the activation of AKT1 (AKT serine/threonine kinase 1) on chromosome 14. This mutation occurs in somatic cells as opposed to germ cells, as in tuberous sclerosis. This difference accounts for the mosaic expression of segmental overgrowth syndromes. This concept has been demonstrated in overgrowth syndromes such as Proteus syndrome, with cells from unaffected areas having different genetic makeup than those from affected tissues.⁵ These mutations, though different, result in the downstream effects of unchecked messenger RNA translation and dysregulated cellular growth.

In our patient, we hypothesized that a small proportion of his postfertilization somatic cells underwent a second de novo mutation in the AKT1 pathway, resulting in the bony overgrowth seen on the left hand. We suspected that this second mutation could be an activation of AKT1, the mutation seen in Proteus syndrome. Sequencing of the tissue may be performed in the future, especially if segmental overgrowth continues and necessitates therapy.

To the Editor:

A 3-year-old boy with a history of tuberous sclerosis presented to our clinic for evaluation of bumps on the second and third fingers of the left hand. Physical examination revealed firm rubbery nodules on the palmar third metacarpophalangeal joint extending to the palm and the lateral aspect of the distal third dorsal finger. There also was asymmetric overgrowth of the left second and third digits consistent with bony segmental overgrowth (Figure).

Tuberous sclerosis and overgrowth syndromes including Proteus syndrome have mutations that share a common pathway, namely the PI3K/AKT/mTOR (phosphoinositide 3-kinase/alpha serine/threonine-protein kinase/mammalian target of rapamycin) pathway.¹ The mutations in tuberous sclerosis involve the loss of TSC1 (TSC complex subunit 1) on chromosome 9 or TSC2 (TSC complex subunit 2) on chromosome 16.² The protein products of these genes, hamartin and tuberin, act together as a tumor suppressor complex.³ The inheritance pattern of tuberous sclerosis is autosomal dominant, though two-thirds of cases are due to de novo germline mutations.⁴ The second copy of the gene must be lost spontaneously in any particular cell for the deleterious effects of the disease to manifest. The mutation in overgrowth syndromes including Proteus syndrome involves the activation of AKT1 (AKT serine/threonine kinase 1) on chromosome 14. This mutation occurs in somatic cells as opposed to germ cells, as in tuberous sclerosis. This difference accounts for the mosaic expression of segmental overgrowth syndromes. This concept has been demonstrated in overgrowth syndromes such as Proteus syndrome, with cells from unaffected areas having different genetic makeup than those from affected tissues.⁵ These mutations, though different, result in the downstream effects of unchecked messenger RNA translation and dysregulated cellular growth.

In our patient, we hypothesized that a small proportion of his postfertilization somatic cells underwent a second de novo mutation in the AKT1 pathway, resulting in the bony overgrowth seen on the left hand. We suspected that this second mutation could be an activation of AKT1, the mutation seen in Proteus syndrome. Sequencing of the tissue may be performed in the future, especially if segmental overgrowth continues and necessitates therapy.

There will be some change for the better when oncology care emerges from the COVID-19 pandemic, the most “revolutionary” being a deep dive into telehealth, predicts Deborah Schrag, MD, MPH, a medical oncologist specializing in gastrointestinal cancers at the Dana Farber Cancer Institute in Boston, Massachusetts.

“In the space of a month, approaches and accepted norms of cancer care delivery have been transformed of necessity,” Schrag and colleagues write in an article published in JAMA on April 13.

“Most of these changes would not have occurred without the pandemic,” they add. They predict that some changes will last after the crisis is over.

“None of us want to be thrown in the deep end.... On the other hand, sometimes it works,” Schrag told Medscape Medical News.

“The in-person visit between patient and physician has been upended,” she said.

“I don’t think there’s any going back to the way it was before because cancer patients won’t stand for it,” she said. “They’re not going to drive in to get the results of a blood test.

“I think that on balance, of course, there are situations where you need eye-to-eye contact. No one wants to have an initial oncology meeting by telehealth – doctors or patients – that’s ridiculous,” she said. “But for follow-up visits, patients are now going to be more demanding, and doctors will be more willing.”

The “essential empathy” of oncologists can still “transcend the new physical barriers presented by masks and telehealth,” Schrag and colleagues comment.

“Doctors are figuring out how to deliver empathy by Zoom,” she told Medscape Medical News. “It’s not the same, but we all convey empathy to our elderly relatives over the phone.”

Pandemic impact on oncology

While the crisis has affected all of medicine – dismantling how care is delivered and forcing clinicians to make difficult decisions regarding triage – the fact that some cancers present an immediate threat to survival means that oncology “provides a lens into the major shifts currently underway in clinical care,” Schrag and colleagues write.

They illustrate the point by highlighting systemic chemotherapy, which is provided to a large proportion of patients with advanced cancer. The pandemic has tipped the risk-benefit ratio away from treatments that have a marginal effect on quality or quantity of life, they note. It has forced an “elimination of low-value treatments that were identified by the Choosing Wisely campaign,” the authors write. Up to now, the uptake of recommendations to eliminate these treatments has been slow.

“For example, for most metastatic solid tumors, chemotherapy beyond the third regimen does not improve survival for more than a few weeks; therefore, oncologists are advising supportive care instead. For patients receiving adjuvant therapy for curable cancers, delaying initiation or abbreviating the number of cycles is appropriate. Oncologists are postponing initiation of adjuvant chemotherapy for some estrogen receptor–negative stage II breast cancers by 8 weeks and administering 6 rather than 12 cycles of adjuvant chemotherapy for stage III colorectal cancers,” Schrag and colleagues write.

On the other hand, even in the epicenters of the pandemic, thus far, oncologists are still delivering cancer treatments that have the potential to cure and cannot safely be delayed, they point out. “This includes most patients with new diagnoses of acute leukemia, high-grade lymphoma, and those with chemotherapy-responsive tumors such as testicular, ovarian, and small cell lung cancer. Despite the risks, oncologists are not modifying such treatments because these cancers are likely more lethal than COVID-19.”

It’s the cancer patients who fall in between these two extremes who pose the biggest treatment challenge during this crisis – the patients for whom a delay would have “moderate clinically important adverse influence on quality of life or survival.” In these cases, oncologists are “prescribing marginally less effective regimens that have lower risk of precipitating hospitalization,” the authors note.

These treatments include the use of “white cell growth factor, more stringent neutrophil counts for proceeding with a next cycle of therapy, and omitting use of steroids to manage nausea.” In addition, where possible, oncologists are substituting oral agents for intravenous agents and “myriad other modifications to minimize visits and hospitalizations.”

Most hospitals and outpatient infusion centers now prohibit visitors from accompanying patients, and oncologists are prioritizing conversations with patients about advance directives, healthcare proxies, and end-of-life care preferences. Yet, even here, telehealth offers a new, enhanced layer to those conversations by enabling families to gather with their loved one and the doctor, she said.

This article first appeared on Medscape.com.

There will be some change for the better when oncology care emerges from the COVID-19 pandemic, the most “revolutionary” being a deep dive into telehealth, predicts Deborah Schrag, MD, MPH, a medical oncologist specializing in gastrointestinal cancers at the Dana Farber Cancer Institute in Boston, Massachusetts.

“In the space of a month, approaches and accepted norms of cancer care delivery have been transformed of necessity,” Schrag and colleagues write in an article published in JAMA on April 13.

“Most of these changes would not have occurred without the pandemic,” they add. They predict that some changes will last after the crisis is over.

“None of us want to be thrown in the deep end.... On the other hand, sometimes it works,” Schrag told Medscape Medical News.

“The in-person visit between patient and physician has been upended,” she said.

“I don’t think there’s any going back to the way it was before because cancer patients won’t stand for it,” she said. “They’re not going to drive in to get the results of a blood test.

“I think that on balance, of course, there are situations where you need eye-to-eye contact. No one wants to have an initial oncology meeting by telehealth – doctors or patients – that’s ridiculous,” she said. “But for follow-up visits, patients are now going to be more demanding, and doctors will be more willing.”

The “essential empathy” of oncologists can still “transcend the new physical barriers presented by masks and telehealth,” Schrag and colleagues comment.

“Doctors are figuring out how to deliver empathy by Zoom,” she told Medscape Medical News. “It’s not the same, but we all convey empathy to our elderly relatives over the phone.”

Pandemic impact on oncology

While the crisis has affected all of medicine – dismantling how care is delivered and forcing clinicians to make difficult decisions regarding triage – the fact that some cancers present an immediate threat to survival means that oncology “provides a lens into the major shifts currently underway in clinical care,” Schrag and colleagues write.

They illustrate the point by highlighting systemic chemotherapy, which is provided to a large proportion of patients with advanced cancer. The pandemic has tipped the risk-benefit ratio away from treatments that have a marginal effect on quality or quantity of life, they note. It has forced an “elimination of low-value treatments that were identified by the Choosing Wisely campaign,” the authors write. Up to now, the uptake of recommendations to eliminate these treatments has been slow.

“For example, for most metastatic solid tumors, chemotherapy beyond the third regimen does not improve survival for more than a few weeks; therefore, oncologists are advising supportive care instead. For patients receiving adjuvant therapy for curable cancers, delaying initiation or abbreviating the number of cycles is appropriate. Oncologists are postponing initiation of adjuvant chemotherapy for some estrogen receptor–negative stage II breast cancers by 8 weeks and administering 6 rather than 12 cycles of adjuvant chemotherapy for stage III colorectal cancers,” Schrag and colleagues write.

On the other hand, even in the epicenters of the pandemic, thus far, oncologists are still delivering cancer treatments that have the potential to cure and cannot safely be delayed, they point out. “This includes most patients with new diagnoses of acute leukemia, high-grade lymphoma, and those with chemotherapy-responsive tumors such as testicular, ovarian, and small cell lung cancer. Despite the risks, oncologists are not modifying such treatments because these cancers are likely more lethal than COVID-19.”

It’s the cancer patients who fall in between these two extremes who pose the biggest treatment challenge during this crisis – the patients for whom a delay would have “moderate clinically important adverse influence on quality of life or survival.” In these cases, oncologists are “prescribing marginally less effective regimens that have lower risk of precipitating hospitalization,” the authors note.

These treatments include the use of “white cell growth factor, more stringent neutrophil counts for proceeding with a next cycle of therapy, and omitting use of steroids to manage nausea.” In addition, where possible, oncologists are substituting oral agents for intravenous agents and “myriad other modifications to minimize visits and hospitalizations.”

Most hospitals and outpatient infusion centers now prohibit visitors from accompanying patients, and oncologists are prioritizing conversations with patients about advance directives, healthcare proxies, and end-of-life care preferences. Yet, even here, telehealth offers a new, enhanced layer to those conversations by enabling families to gather with their loved one and the doctor, she said.

This article first appeared on Medscape.com.

There will be some change for the better when oncology care emerges from the COVID-19 pandemic, the most “revolutionary” being a deep dive into telehealth, predicts Deborah Schrag, MD, MPH, a medical oncologist specializing in gastrointestinal cancers at the Dana Farber Cancer Institute in Boston, Massachusetts.

“In the space of a month, approaches and accepted norms of cancer care delivery have been transformed of necessity,” Schrag and colleagues write in an article published in JAMA on April 13.

“Most of these changes would not have occurred without the pandemic,” they add. They predict that some changes will last after the crisis is over.

“None of us want to be thrown in the deep end.... On the other hand, sometimes it works,” Schrag told Medscape Medical News.

“The in-person visit between patient and physician has been upended,” she said.

“I don’t think there’s any going back to the way it was before because cancer patients won’t stand for it,” she said. “They’re not going to drive in to get the results of a blood test.

“I think that on balance, of course, there are situations where you need eye-to-eye contact. No one wants to have an initial oncology meeting by telehealth – doctors or patients – that’s ridiculous,” she said. “But for follow-up visits, patients are now going to be more demanding, and doctors will be more willing.”

The “essential empathy” of oncologists can still “transcend the new physical barriers presented by masks and telehealth,” Schrag and colleagues comment.

“Doctors are figuring out how to deliver empathy by Zoom,” she told Medscape Medical News. “It’s not the same, but we all convey empathy to our elderly relatives over the phone.”

Pandemic impact on oncology

While the crisis has affected all of medicine – dismantling how care is delivered and forcing clinicians to make difficult decisions regarding triage – the fact that some cancers present an immediate threat to survival means that oncology “provides a lens into the major shifts currently underway in clinical care,” Schrag and colleagues write.

They illustrate the point by highlighting systemic chemotherapy, which is provided to a large proportion of patients with advanced cancer. The pandemic has tipped the risk-benefit ratio away from treatments that have a marginal effect on quality or quantity of life, they note. It has forced an “elimination of low-value treatments that were identified by the Choosing Wisely campaign,” the authors write. Up to now, the uptake of recommendations to eliminate these treatments has been slow.

“For example, for most metastatic solid tumors, chemotherapy beyond the third regimen does not improve survival for more than a few weeks; therefore, oncologists are advising supportive care instead. For patients receiving adjuvant therapy for curable cancers, delaying initiation or abbreviating the number of cycles is appropriate. Oncologists are postponing initiation of adjuvant chemotherapy for some estrogen receptor–negative stage II breast cancers by 8 weeks and administering 6 rather than 12 cycles of adjuvant chemotherapy for stage III colorectal cancers,” Schrag and colleagues write.

On the other hand, even in the epicenters of the pandemic, thus far, oncologists are still delivering cancer treatments that have the potential to cure and cannot safely be delayed, they point out. “This includes most patients with new diagnoses of acute leukemia, high-grade lymphoma, and those with chemotherapy-responsive tumors such as testicular, ovarian, and small cell lung cancer. Despite the risks, oncologists are not modifying such treatments because these cancers are likely more lethal than COVID-19.”

It’s the cancer patients who fall in between these two extremes who pose the biggest treatment challenge during this crisis – the patients for whom a delay would have “moderate clinically important adverse influence on quality of life or survival.” In these cases, oncologists are “prescribing marginally less effective regimens that have lower risk of precipitating hospitalization,” the authors note.

These treatments include the use of “white cell growth factor, more stringent neutrophil counts for proceeding with a next cycle of therapy, and omitting use of steroids to manage nausea.” In addition, where possible, oncologists are substituting oral agents for intravenous agents and “myriad other modifications to minimize visits and hospitalizations.”

Most hospitals and outpatient infusion centers now prohibit visitors from accompanying patients, and oncologists are prioritizing conversations with patients about advance directives, healthcare proxies, and end-of-life care preferences. Yet, even here, telehealth offers a new, enhanced layer to those conversations by enabling families to gather with their loved one and the doctor, she said.

This article first appeared on Medscape.com.

Although priority number one lies in controlling the spread of COVID-19, public health researchers are calling attention to the long-term repercussions of the pandemic on children’s health.

School closures could noticeably worsen the epidemic of childhood obesity that already threatens many children in the United States, say Paul Rundle, DrPH, and colleagues from Columbia University Mailman School of Public Health, New York City, in a perspective published online March 30 in Obesity.

“In part, we wrote the perspective to remind people that summer unhealthy weight gain seems to accumulate year to year,” he told Medscape Medical News in an email.

Rundle and colleagues estimate that time spent out of school will double this year because of school closures due to COVID-19. That, along with shelter-in-place orders, will pose challenges both for physical activity and healthy eating among children.

In addition, playgrounds have closed in many areas, and even where parks remain open, social distancing decreases opportunities for exercise. Team sports are on hold, and without physical education taught in schools, many children will not be getting as much active outdoor play as needed.

That’s especially true for children in urban areas, who may find it even more difficult to exercise inside cramped apartments, they add.

As a result, more and more children may turn to sedentary activities, and increased screen time goes hand in hand with childhood overweight and obesity, not just because of the lack of exercise but also because of snacking on unhealthy, empty-calorie foods while glued to the screen.

“We were hoping to get the word out on this issue, do some education or reminding, and at least let people know that this should be something to keep an eye on, among so many other things,” Rundle added.

Excess Eating Because of Stress and Boredom

Jessica Sparks Lilley, MD, director of the Pediatric Diabetes and Lipid Program at the Mississippi Center for Advanced Medicine in Madison, agrees that it is crucial to address these issues.

“Just like adults, children eat in response to emotions, including stress and boredom, and stress levels are high during these uncertain times,” she told Medscape Medical News.

Although both Rundle and Sparks Lilley acknowledged the challenges of finding good solutions at this time, they do offer some tips.

Schools should make physical education and at-home exercise a priority alongside other remote teaching. Physical education teachers could even stream exercise classes to children at home.

Even just walking in the park while maintaining social distancing could be better than nothing, and a brisk walk is probably even better.

Depending on the age of the child, online yoga may also be useful. Even though yoga burns relatively few calories, it incorporates mindfulness training that may be helpful.

“I think focusing on promoting mindful eating as compared to mindless or distracted eating is important. Even in the best of circumstances, it is hard to exercise enough to burn off high energy snacks,” Rundle said.

Additional Stressors From Poverty: Schools Can Help With Meals

Children living in poverty, already the most vulnerable to obesity and related health problems, have additional stressors, add the two experts.

“As more Americans are losing jobs, poverty is a real threat to many of the children I care for. Families living in poverty often rely on processed, high-calorie, low-nutrient foods for survival, because they are inexpensive and shelf-stable,” Sparks Lilley said.

Rundle and colleagues agree: “Our own experiences in supermarkets show...shelves that held...crackers, chips, ramen noodles, soda, sugary cereals, and processed ready-to-eat meals are quite empty. We anticipate that many children will experience higher calorie diets during the pandemic response.”

Similar to how they address food insecurity during summer holidays, school districts have responded by offering grab-and-go meals, Rundle and colleagues note.

To maintain social distancing for people with vulnerable family members, some school districts have also started delivering food using school buses that run along regularly scheduled routes.

Rundle also stresses that farmers’ markets, which often provide foods that appeal to immigrant and ethnic communities, should be considered part of essential food services.

As such, social distancing protocols should be established for them and they should be allowed to stay open, he argues.

“The safety of American children is at stake in many ways. The threat to themselves or their caregivers being infected with COVID-19 is rightly foremost in our concerns,” Sparks Lilley stressed.

“However, there is other fallout to consider. We’ve seen very clearly the need for public health and preventive medicine and can’t let vulnerable children fall through the cracks.”

Rundle agrees. Although it is a “priority” to mitigate the immediate impact of COVID-19, “it is important to consider ways to prevent its long-term effects, including new risks for childhood obesity.”

Rundle and coauthors, as well as Sparks Lilley, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Although priority number one lies in controlling the spread of COVID-19, public health researchers are calling attention to the long-term repercussions of the pandemic on children’s health.

School closures could noticeably worsen the epidemic of childhood obesity that already threatens many children in the United States, say Paul Rundle, DrPH, and colleagues from Columbia University Mailman School of Public Health, New York City, in a perspective published online March 30 in Obesity.

“In part, we wrote the perspective to remind people that summer unhealthy weight gain seems to accumulate year to year,” he told Medscape Medical News in an email.

Rundle and colleagues estimate that time spent out of school will double this year because of school closures due to COVID-19. That, along with shelter-in-place orders, will pose challenges both for physical activity and healthy eating among children.

In addition, playgrounds have closed in many areas, and even where parks remain open, social distancing decreases opportunities for exercise. Team sports are on hold, and without physical education taught in schools, many children will not be getting as much active outdoor play as needed.

That’s especially true for children in urban areas, who may find it even more difficult to exercise inside cramped apartments, they add.

As a result, more and more children may turn to sedentary activities, and increased screen time goes hand in hand with childhood overweight and obesity, not just because of the lack of exercise but also because of snacking on unhealthy, empty-calorie foods while glued to the screen.

“We were hoping to get the word out on this issue, do some education or reminding, and at least let people know that this should be something to keep an eye on, among so many other things,” Rundle added.

Excess Eating Because of Stress and Boredom

Jessica Sparks Lilley, MD, director of the Pediatric Diabetes and Lipid Program at the Mississippi Center for Advanced Medicine in Madison, agrees that it is crucial to address these issues.

“Just like adults, children eat in response to emotions, including stress and boredom, and stress levels are high during these uncertain times,” she told Medscape Medical News.

Although both Rundle and Sparks Lilley acknowledged the challenges of finding good solutions at this time, they do offer some tips.

Schools should make physical education and at-home exercise a priority alongside other remote teaching. Physical education teachers could even stream exercise classes to children at home.

Even just walking in the park while maintaining social distancing could be better than nothing, and a brisk walk is probably even better.

Depending on the age of the child, online yoga may also be useful. Even though yoga burns relatively few calories, it incorporates mindfulness training that may be helpful.

“I think focusing on promoting mindful eating as compared to mindless or distracted eating is important. Even in the best of circumstances, it is hard to exercise enough to burn off high energy snacks,” Rundle said.

Additional Stressors From Poverty: Schools Can Help With Meals

Children living in poverty, already the most vulnerable to obesity and related health problems, have additional stressors, add the two experts.

“As more Americans are losing jobs, poverty is a real threat to many of the children I care for. Families living in poverty often rely on processed, high-calorie, low-nutrient foods for survival, because they are inexpensive and shelf-stable,” Sparks Lilley said.

Rundle and colleagues agree: “Our own experiences in supermarkets show...shelves that held...crackers, chips, ramen noodles, soda, sugary cereals, and processed ready-to-eat meals are quite empty. We anticipate that many children will experience higher calorie diets during the pandemic response.”

Similar to how they address food insecurity during summer holidays, school districts have responded by offering grab-and-go meals, Rundle and colleagues note.

To maintain social distancing for people with vulnerable family members, some school districts have also started delivering food using school buses that run along regularly scheduled routes.

Rundle also stresses that farmers’ markets, which often provide foods that appeal to immigrant and ethnic communities, should be considered part of essential food services.

As such, social distancing protocols should be established for them and they should be allowed to stay open, he argues.

“The safety of American children is at stake in many ways. The threat to themselves or their caregivers being infected with COVID-19 is rightly foremost in our concerns,” Sparks Lilley stressed.

“However, there is other fallout to consider. We’ve seen very clearly the need for public health and preventive medicine and can’t let vulnerable children fall through the cracks.”

Rundle agrees. Although it is a “priority” to mitigate the immediate impact of COVID-19, “it is important to consider ways to prevent its long-term effects, including new risks for childhood obesity.”

Rundle and coauthors, as well as Sparks Lilley, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Although priority number one lies in controlling the spread of COVID-19, public health researchers are calling attention to the long-term repercussions of the pandemic on children’s health.

School closures could noticeably worsen the epidemic of childhood obesity that already threatens many children in the United States, say Paul Rundle, DrPH, and colleagues from Columbia University Mailman School of Public Health, New York City, in a perspective published online March 30 in Obesity.

“In part, we wrote the perspective to remind people that summer unhealthy weight gain seems to accumulate year to year,” he told Medscape Medical News in an email.

Rundle and colleagues estimate that time spent out of school will double this year because of school closures due to COVID-19. That, along with shelter-in-place orders, will pose challenges both for physical activity and healthy eating among children.

In addition, playgrounds have closed in many areas, and even where parks remain open, social distancing decreases opportunities for exercise. Team sports are on hold, and without physical education taught in schools, many children will not be getting as much active outdoor play as needed.

That’s especially true for children in urban areas, who may find it even more difficult to exercise inside cramped apartments, they add.

As a result, more and more children may turn to sedentary activities, and increased screen time goes hand in hand with childhood overweight and obesity, not just because of the lack of exercise but also because of snacking on unhealthy, empty-calorie foods while glued to the screen.

“We were hoping to get the word out on this issue, do some education or reminding, and at least let people know that this should be something to keep an eye on, among so many other things,” Rundle added.

Excess Eating Because of Stress and Boredom

Jessica Sparks Lilley, MD, director of the Pediatric Diabetes and Lipid Program at the Mississippi Center for Advanced Medicine in Madison, agrees that it is crucial to address these issues.

“Just like adults, children eat in response to emotions, including stress and boredom, and stress levels are high during these uncertain times,” she told Medscape Medical News.

Although both Rundle and Sparks Lilley acknowledged the challenges of finding good solutions at this time, they do offer some tips.

Schools should make physical education and at-home exercise a priority alongside other remote teaching. Physical education teachers could even stream exercise classes to children at home.

Even just walking in the park while maintaining social distancing could be better than nothing, and a brisk walk is probably even better.

Depending on the age of the child, online yoga may also be useful. Even though yoga burns relatively few calories, it incorporates mindfulness training that may be helpful.

“I think focusing on promoting mindful eating as compared to mindless or distracted eating is important. Even in the best of circumstances, it is hard to exercise enough to burn off high energy snacks,” Rundle said.

Additional Stressors From Poverty: Schools Can Help With Meals

Children living in poverty, already the most vulnerable to obesity and related health problems, have additional stressors, add the two experts.

“As more Americans are losing jobs, poverty is a real threat to many of the children I care for. Families living in poverty often rely on processed, high-calorie, low-nutrient foods for survival, because they are inexpensive and shelf-stable,” Sparks Lilley said.

Rundle and colleagues agree: “Our own experiences in supermarkets show...shelves that held...crackers, chips, ramen noodles, soda, sugary cereals, and processed ready-to-eat meals are quite empty. We anticipate that many children will experience higher calorie diets during the pandemic response.”

Similar to how they address food insecurity during summer holidays, school districts have responded by offering grab-and-go meals, Rundle and colleagues note.

To maintain social distancing for people with vulnerable family members, some school districts have also started delivering food using school buses that run along regularly scheduled routes.

Rundle also stresses that farmers’ markets, which often provide foods that appeal to immigrant and ethnic communities, should be considered part of essential food services.

As such, social distancing protocols should be established for them and they should be allowed to stay open, he argues.

“The safety of American children is at stake in many ways. The threat to themselves or their caregivers being infected with COVID-19 is rightly foremost in our concerns,” Sparks Lilley stressed.

“However, there is other fallout to consider. We’ve seen very clearly the need for public health and preventive medicine and can’t let vulnerable children fall through the cracks.”

Rundle agrees. Although it is a “priority” to mitigate the immediate impact of COVID-19, “it is important to consider ways to prevent its long-term effects, including new risks for childhood obesity.”

Rundle and coauthors, as well as Sparks Lilley, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Coronavirus disease of 2019, more commonly referred to as COVID-19, is caused by a novel coronavirus. At press time in April, its diagnosis had been confirmed in more than 2 million individuals in 185 countries and territories since first isolated in January 2020. Daily updates are provided in terms of the number of new cases, the evolving strategies to mitigate additional spread, testing, potential drug trials, and vaccine development. Risk groups for development of severe disease also have been widely publicized. Limited information has been provided about COVID-19 in children.

Courtesy NIAID-RML

Terminology

Endemic. The condition is present at a stable predictable rate in a community. The number observed is what is expected.

Outbreak. The number of cases is greater than what is expected in the area.

Epidemic. An outbreak that spreads over a larger geographical area.

Pandemic. An outbreak that has spread to multiple countries and /or continents.



What we know about coronaviruses: They are host-specific RNA viruses widespread in bats, but found in many other species including humans. Previously, six species caused disease in humans. Four species: 229E, NL63, OC43, and HKU1 usually cause the common cold. Symptoms are generally self-limited and peak 3-4 days after onset. Infection rarely can be manifested as otitis media or a lower respiratory tract disease.

In February 2003, SARS-CoV, a novel coronavirus, was identified as the causative agent for an outbreak of a severe acute respiratory syndrome (SARS) which began in Guangdong, China. It became a pandemic that occurred between November 2002 and July 2003. More than 8,000 individuals from 26 countries were infected, and there were 774 deaths, according to the Centers for Disease Control and Prevention. No cases have been reported since April 2004. This virus most often infected adults, and the mortality rate was 10%. No pediatric deaths were reported. The virus was considered to have evolved from a bat CoV with civet cats as an intermediate host.

In September 2012, MERS-CoV (Middle East respiratory syndrome), another novel coronavirus also manifesting as a severe respiratory illness, was identified in Saudi Arabia. Current data suggests it evolved from a bat CoV using dromedary camels as an intermediate host. To date, more than 2,400 cases have been reported with a case fatality rate of approximately 35% (Emerg Infect Dis. 2020 Feb; 26[2]:191-8). Disease in children has been mild. Most cases have been identified in adult males with comorbidities and have been reported from Saudi Arabia (85%). To date, no sustained human-to-human transmission has been documented. However, limited nonsustained human-to-human transmission has occurred in health care settings.


 

Preliminary COVID-19 pediatric data

Multiple case reports and studies with limited numbers of patients have been quickly published, but limited data about children have been available. A large study by Wu et al. was released. Epidemiologic data were available for 72,314 cases (62% confirmed 22% suspected,15% diagnosed based on clinical symptoms). Only 965 (1.3%) cases occurred in persons under 19 years of age. There were no deaths reported in anyone younger than 9 years old. The authors indicated that 889 patients (1%) were asymptomatic, but the exact number of children in that group was not provided.¹

Dong Y et al. reported on the epidemiologic characteristics of 2,135 children under 18 years who resided in or near an epidemic center. Data were obtained retrospectively; 34% (728) of the cases were confirmed and 66% (1,407) were suspected. In summary, 94 (4%) of all patients were asymptomatic, 1,088 (51%) had mild symptoms, and 826 (39%) had moderate symptoms at the time of diagnosis. The remaining 6% of patients (125) had severe/critical disease manifested by dyspnea and hypoxemia. Interestingly, more severe/critical cases were in the suspected group. Could another pathogen be the true etiology? Severity of illness was greatest for infants (11%). As of Feb. 8, 2020, only one child had died; he was 14 years old. This study supports the claim that COVID-19 disease in children is less severe than in adults.²

Data in U.S. children are now available. Between Feb. 12, 2020, and April 2, 2020, there were 149,770 cases of laboratory-confirmed COVID-19 reported to the CDC. Age was documented in 149,082 cases and 2, 572 (1.7%) were in persons younger than 18 years. New York had the highest percentage of reported pediatric cases at 33% from New York City, and 23% from the remainder of New York state; an additional 15% were from New Jersey and the remaining 29% of cases were from other areas. The median age was 11 years. Cases by age were 32% in teens aged 15-17 years; 27% in children aged 10-14 years; 15% in children aged 5-9 years; 11% in children aged 1-4 years; and 15% in children aged less than 1 year.

Exposure history was documented in 184 cases, of which 91% were household /community. Information regarding signs and symptoms were limited but not absent. Based on available data, 73% of children had fever, cough, or shortness of breath. When looked at independently, each of these symptoms occurred less frequently than in adults: 56% of children reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43% of adults, respectively. Also reported less frequently were myalgia, headache, sore throat, and diarrhea.

Hospitalization status was available for 745 children, with 20% being hospitalized and 2% being admitted to the ICU. Children under 1 year accounted for most of the hospitalizations. Limited information about underlying conditions was provided. Among 345 cases, 23% had at least one underlying medical condition; the most common conditions were chronic lung disease including asthma (50%), cardiovascular disease (31%), and immunosuppression (8%). Three deaths were reported in this cohort of 2,135 children; however, the final cause of death is still under review.³

There are limitations to the data. Many of the answers needed to perform adequate analysis regarding symptoms, their duration and severity, risk factors, etc., were not available. Routine testing is not currently recommended, and current practices may influence the outcomes.

What have we learned? The data suggest that most ill children may not have cough, fever, or shortness of breath; symptoms which parents will be looking for prior to even seeking medical attention. These are the individuals who may likely play a continued role with disease transmission. The need for hospitalization and the severity of illness appears to be lower than in adults but not absent. Strategies to mitigate additional spread such as social distancing, wearing facial masks, and hand washing still are important and should be encouraged.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures. Email Dr. Word at [email protected].

References

1. JAMA. 2020;323(13):1239-42.

2. Pediatrics. 2020:145(6): e20200702.

3. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69:422-6.

Coronavirus disease of 2019, more commonly referred to as COVID-19, is caused by a novel coronavirus. At press time in April, its diagnosis had been confirmed in more than 2 million individuals in 185 countries and territories since first isolated in January 2020. Daily updates are provided in terms of the number of new cases, the evolving strategies to mitigate additional spread, testing, potential drug trials, and vaccine development. Risk groups for development of severe disease also have been widely publicized. Limited information has been provided about COVID-19 in children.

Courtesy NIAID-RML

Terminology

Endemic. The condition is present at a stable predictable rate in a community. The number observed is what is expected.

Outbreak. The number of cases is greater than what is expected in the area.

Epidemic. An outbreak that spreads over a larger geographical area.

Pandemic. An outbreak that has spread to multiple countries and /or continents.



What we know about coronaviruses: They are host-specific RNA viruses widespread in bats, but found in many other species including humans. Previously, six species caused disease in humans. Four species: 229E, NL63, OC43, and HKU1 usually cause the common cold. Symptoms are generally self-limited and peak 3-4 days after onset. Infection rarely can be manifested as otitis media or a lower respiratory tract disease.

In February 2003, SARS-CoV, a novel coronavirus, was identified as the causative agent for an outbreak of a severe acute respiratory syndrome (SARS) which began in Guangdong, China. It became a pandemic that occurred between November 2002 and July 2003. More than 8,000 individuals from 26 countries were infected, and there were 774 deaths, according to the Centers for Disease Control and Prevention. No cases have been reported since April 2004. This virus most often infected adults, and the mortality rate was 10%. No pediatric deaths were reported. The virus was considered to have evolved from a bat CoV with civet cats as an intermediate host.

In September 2012, MERS-CoV (Middle East respiratory syndrome), another novel coronavirus also manifesting as a severe respiratory illness, was identified in Saudi Arabia. Current data suggests it evolved from a bat CoV using dromedary camels as an intermediate host. To date, more than 2,400 cases have been reported with a case fatality rate of approximately 35% (Emerg Infect Dis. 2020 Feb; 26[2]:191-8). Disease in children has been mild. Most cases have been identified in adult males with comorbidities and have been reported from Saudi Arabia (85%). To date, no sustained human-to-human transmission has been documented. However, limited nonsustained human-to-human transmission has occurred in health care settings.


 

Preliminary COVID-19 pediatric data

Multiple case reports and studies with limited numbers of patients have been quickly published, but limited data about children have been available. A large study by Wu et al. was released. Epidemiologic data were available for 72,314 cases (62% confirmed 22% suspected,15% diagnosed based on clinical symptoms). Only 965 (1.3%) cases occurred in persons under 19 years of age. There were no deaths reported in anyone younger than 9 years old. The authors indicated that 889 patients (1%) were asymptomatic, but the exact number of children in that group was not provided.¹

Dong Y et al. reported on the epidemiologic characteristics of 2,135 children under 18 years who resided in or near an epidemic center. Data were obtained retrospectively; 34% (728) of the cases were confirmed and 66% (1,407) were suspected. In summary, 94 (4%) of all patients were asymptomatic, 1,088 (51%) had mild symptoms, and 826 (39%) had moderate symptoms at the time of diagnosis. The remaining 6% of patients (125) had severe/critical disease manifested by dyspnea and hypoxemia. Interestingly, more severe/critical cases were in the suspected group. Could another pathogen be the true etiology? Severity of illness was greatest for infants (11%). As of Feb. 8, 2020, only one child had died; he was 14 years old. This study supports the claim that COVID-19 disease in children is less severe than in adults.²

Data in U.S. children are now available. Between Feb. 12, 2020, and April 2, 2020, there were 149,770 cases of laboratory-confirmed COVID-19 reported to the CDC. Age was documented in 149,082 cases and 2, 572 (1.7%) were in persons younger than 18 years. New York had the highest percentage of reported pediatric cases at 33% from New York City, and 23% from the remainder of New York state; an additional 15% were from New Jersey and the remaining 29% of cases were from other areas. The median age was 11 years. Cases by age were 32% in teens aged 15-17 years; 27% in children aged 10-14 years; 15% in children aged 5-9 years; 11% in children aged 1-4 years; and 15% in children aged less than 1 year.

Exposure history was documented in 184 cases, of which 91% were household /community. Information regarding signs and symptoms were limited but not absent. Based on available data, 73% of children had fever, cough, or shortness of breath. When looked at independently, each of these symptoms occurred less frequently than in adults: 56% of children reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43% of adults, respectively. Also reported less frequently were myalgia, headache, sore throat, and diarrhea.

Hospitalization status was available for 745 children, with 20% being hospitalized and 2% being admitted to the ICU. Children under 1 year accounted for most of the hospitalizations. Limited information about underlying conditions was provided. Among 345 cases, 23% had at least one underlying medical condition; the most common conditions were chronic lung disease including asthma (50%), cardiovascular disease (31%), and immunosuppression (8%). Three deaths were reported in this cohort of 2,135 children; however, the final cause of death is still under review.³

There are limitations to the data. Many of the answers needed to perform adequate analysis regarding symptoms, their duration and severity, risk factors, etc., were not available. Routine testing is not currently recommended, and current practices may influence the outcomes.

What have we learned? The data suggest that most ill children may not have cough, fever, or shortness of breath; symptoms which parents will be looking for prior to even seeking medical attention. These are the individuals who may likely play a continued role with disease transmission. The need for hospitalization and the severity of illness appears to be lower than in adults but not absent. Strategies to mitigate additional spread such as social distancing, wearing facial masks, and hand washing still are important and should be encouraged.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures. Email Dr. Word at [email protected].

References

1. JAMA. 2020;323(13):1239-42.

2. Pediatrics. 2020:145(6): e20200702.

3. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69:422-6.

Coronavirus disease of 2019, more commonly referred to as COVID-19, is caused by a novel coronavirus. At press time in April, its diagnosis had been confirmed in more than 2 million individuals in 185 countries and territories since first isolated in January 2020. Daily updates are provided in terms of the number of new cases, the evolving strategies to mitigate additional spread, testing, potential drug trials, and vaccine development. Risk groups for development of severe disease also have been widely publicized. Limited information has been provided about COVID-19 in children.

Courtesy NIAID-RML

Terminology

Endemic. The condition is present at a stable predictable rate in a community. The number observed is what is expected.

Outbreak. The number of cases is greater than what is expected in the area.

Epidemic. An outbreak that spreads over a larger geographical area.

Pandemic. An outbreak that has spread to multiple countries and /or continents.



What we know about coronaviruses: They are host-specific RNA viruses widespread in bats, but found in many other species including humans. Previously, six species caused disease in humans. Four species: 229E, NL63, OC43, and HKU1 usually cause the common cold. Symptoms are generally self-limited and peak 3-4 days after onset. Infection rarely can be manifested as otitis media or a lower respiratory tract disease.

In February 2003, SARS-CoV, a novel coronavirus, was identified as the causative agent for an outbreak of a severe acute respiratory syndrome (SARS) which began in Guangdong, China. It became a pandemic that occurred between November 2002 and July 2003. More than 8,000 individuals from 26 countries were infected, and there were 774 deaths, according to the Centers for Disease Control and Prevention. No cases have been reported since April 2004. This virus most often infected adults, and the mortality rate was 10%. No pediatric deaths were reported. The virus was considered to have evolved from a bat CoV with civet cats as an intermediate host.

In September 2012, MERS-CoV (Middle East respiratory syndrome), another novel coronavirus also manifesting as a severe respiratory illness, was identified in Saudi Arabia. Current data suggests it evolved from a bat CoV using dromedary camels as an intermediate host. To date, more than 2,400 cases have been reported with a case fatality rate of approximately 35% (Emerg Infect Dis. 2020 Feb; 26[2]:191-8). Disease in children has been mild. Most cases have been identified in adult males with comorbidities and have been reported from Saudi Arabia (85%). To date, no sustained human-to-human transmission has been documented. However, limited nonsustained human-to-human transmission has occurred in health care settings.


 

Preliminary COVID-19 pediatric data

Multiple case reports and studies with limited numbers of patients have been quickly published, but limited data about children have been available. A large study by Wu et al. was released. Epidemiologic data were available for 72,314 cases (62% confirmed 22% suspected,15% diagnosed based on clinical symptoms). Only 965 (1.3%) cases occurred in persons under 19 years of age. There were no deaths reported in anyone younger than 9 years old. The authors indicated that 889 patients (1%) were asymptomatic, but the exact number of children in that group was not provided.¹

Dong Y et al. reported on the epidemiologic characteristics of 2,135 children under 18 years who resided in or near an epidemic center. Data were obtained retrospectively; 34% (728) of the cases were confirmed and 66% (1,407) were suspected. In summary, 94 (4%) of all patients were asymptomatic, 1,088 (51%) had mild symptoms, and 826 (39%) had moderate symptoms at the time of diagnosis. The remaining 6% of patients (125) had severe/critical disease manifested by dyspnea and hypoxemia. Interestingly, more severe/critical cases were in the suspected group. Could another pathogen be the true etiology? Severity of illness was greatest for infants (11%). As of Feb. 8, 2020, only one child had died; he was 14 years old. This study supports the claim that COVID-19 disease in children is less severe than in adults.²

Data in U.S. children are now available. Between Feb. 12, 2020, and April 2, 2020, there were 149,770 cases of laboratory-confirmed COVID-19 reported to the CDC. Age was documented in 149,082 cases and 2, 572 (1.7%) were in persons younger than 18 years. New York had the highest percentage of reported pediatric cases at 33% from New York City, and 23% from the remainder of New York state; an additional 15% were from New Jersey and the remaining 29% of cases were from other areas. The median age was 11 years. Cases by age were 32% in teens aged 15-17 years; 27% in children aged 10-14 years; 15% in children aged 5-9 years; 11% in children aged 1-4 years; and 15% in children aged less than 1 year.

Exposure history was documented in 184 cases, of which 91% were household /community. Information regarding signs and symptoms were limited but not absent. Based on available data, 73% of children had fever, cough, or shortness of breath. When looked at independently, each of these symptoms occurred less frequently than in adults: 56% of children reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43% of adults, respectively. Also reported less frequently were myalgia, headache, sore throat, and diarrhea.

Hospitalization status was available for 745 children, with 20% being hospitalized and 2% being admitted to the ICU. Children under 1 year accounted for most of the hospitalizations. Limited information about underlying conditions was provided. Among 345 cases, 23% had at least one underlying medical condition; the most common conditions were chronic lung disease including asthma (50%), cardiovascular disease (31%), and immunosuppression (8%). Three deaths were reported in this cohort of 2,135 children; however, the final cause of death is still under review.³

There are limitations to the data. Many of the answers needed to perform adequate analysis regarding symptoms, their duration and severity, risk factors, etc., were not available. Routine testing is not currently recommended, and current practices may influence the outcomes.

What have we learned? The data suggest that most ill children may not have cough, fever, or shortness of breath; symptoms which parents will be looking for prior to even seeking medical attention. These are the individuals who may likely play a continued role with disease transmission. The need for hospitalization and the severity of illness appears to be lower than in adults but not absent. Strategies to mitigate additional spread such as social distancing, wearing facial masks, and hand washing still are important and should be encouraged.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures. Email Dr. Word at [email protected].

References

1. JAMA. 2020;323(13):1239-42.

2. Pediatrics. 2020:145(6): e20200702.

3. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69:422-6.

My patients and their families have never been more anxious. In the pediatric ED where I practice, everyone is on edge. The COVID-19 pandemic has amplified the feelings of anxious anticipation and uncertainty that families have when they bring their child to the ED. People are scared that their children have the virus or that they will contract it in this high-risk environment. Both are reasonable fears. As a doctor, it has never been more difficult for me to lessen that anxiety.

Every doctor has a version of an interpersonal toolkit they use to project confidence, maintain calm, and convey empathy. Parts of it are taught in medical school, but most components are learned by trial and error. For me, it starts with speaking clearly and directly. If I can do this successfully, it allows parents to understand my recommendations and feel comfortable with my expertise. But words alone are rarely enough to gain trust. For most people, trusting a doctor requires believing that the physician is empathetic and invested in their care or the care of their loved one.

My experience is that, in the short, high-intensity interactions of the ED, this often has to be achieved with body language and facial expressions. We use so many little movements in interactions with patients: a knowing smile, kind eyes, a timely frown, open arms. These gestures would typically show parents I understand how they feel, and I am invested in the health of their child. Hidden behind my mask, face shield, gown, and gloves, I remain a black box. I dispense advice but struggle to convey that it comes from someone who cares.

At the beginning of the pandemic, I would skirt the rules of personal protective equipment (PPE) usage to try and get a moment of human connection. I might appear in the doorway of a patient’s room, smile, and introduce myself before putting on my mask and goggles. If a parent seemed to expect a firm handshake, I would give one, careful to wash my hands before and after. As the guidelines around PPE usage have become more consistent and the danger of the virus increasingly evident, I have cut out these little indulgences. I wear a mask and eye protection from the moment I enter the ED until I leave. I touch as few patients as possible and generally stand 6 feet or more from everyone I talk to.

I believe most providers would agree; these precautions are the only ethical way to see patients during the pandemic. Patients and families are entitled to health care workers who are doing everything they can to protect themselves and those around them. As long as the pandemic lasts, patients and providers will need to recalibrate their expectations of interpersonal interactions. For the time being, good doctors might be defined as much by their PPE adherence as by their ability to connect with patients.

Dr. Shapiro is a clinical instructor of pediatrics at the George Washington University and a clinical associate in the division of emergency medicine at Children’s National Hospital, both in Washington. He said he had no relevant financial disclosures. Email Dr. Shapiro at [email protected].

My patients and their families have never been more anxious. In the pediatric ED where I practice, everyone is on edge. The COVID-19 pandemic has amplified the feelings of anxious anticipation and uncertainty that families have when they bring their child to the ED. People are scared that their children have the virus or that they will contract it in this high-risk environment. Both are reasonable fears. As a doctor, it has never been more difficult for me to lessen that anxiety.

Every doctor has a version of an interpersonal toolkit they use to project confidence, maintain calm, and convey empathy. Parts of it are taught in medical school, but most components are learned by trial and error. For me, it starts with speaking clearly and directly. If I can do this successfully, it allows parents to understand my recommendations and feel comfortable with my expertise. But words alone are rarely enough to gain trust. For most people, trusting a doctor requires believing that the physician is empathetic and invested in their care or the care of their loved one.

My experience is that, in the short, high-intensity interactions of the ED, this often has to be achieved with body language and facial expressions. We use so many little movements in interactions with patients: a knowing smile, kind eyes, a timely frown, open arms. These gestures would typically show parents I understand how they feel, and I am invested in the health of their child. Hidden behind my mask, face shield, gown, and gloves, I remain a black box. I dispense advice but struggle to convey that it comes from someone who cares.

At the beginning of the pandemic, I would skirt the rules of personal protective equipment (PPE) usage to try and get a moment of human connection. I might appear in the doorway of a patient’s room, smile, and introduce myself before putting on my mask and goggles. If a parent seemed to expect a firm handshake, I would give one, careful to wash my hands before and after. As the guidelines around PPE usage have become more consistent and the danger of the virus increasingly evident, I have cut out these little indulgences. I wear a mask and eye protection from the moment I enter the ED until I leave. I touch as few patients as possible and generally stand 6 feet or more from everyone I talk to.

I believe most providers would agree; these precautions are the only ethical way to see patients during the pandemic. Patients and families are entitled to health care workers who are doing everything they can to protect themselves and those around them. As long as the pandemic lasts, patients and providers will need to recalibrate their expectations of interpersonal interactions. For the time being, good doctors might be defined as much by their PPE adherence as by their ability to connect with patients.

Dr. Shapiro is a clinical instructor of pediatrics at the George Washington University and a clinical associate in the division of emergency medicine at Children’s National Hospital, both in Washington. He said he had no relevant financial disclosures. Email Dr. Shapiro at [email protected].

My patients and their families have never been more anxious. In the pediatric ED where I practice, everyone is on edge. The COVID-19 pandemic has amplified the feelings of anxious anticipation and uncertainty that families have when they bring their child to the ED. People are scared that their children have the virus or that they will contract it in this high-risk environment. Both are reasonable fears. As a doctor, it has never been more difficult for me to lessen that anxiety.

Every doctor has a version of an interpersonal toolkit they use to project confidence, maintain calm, and convey empathy. Parts of it are taught in medical school, but most components are learned by trial and error. For me, it starts with speaking clearly and directly. If I can do this successfully, it allows parents to understand my recommendations and feel comfortable with my expertise. But words alone are rarely enough to gain trust. For most people, trusting a doctor requires believing that the physician is empathetic and invested in their care or the care of their loved one.

My experience is that, in the short, high-intensity interactions of the ED, this often has to be achieved with body language and facial expressions. We use so many little movements in interactions with patients: a knowing smile, kind eyes, a timely frown, open arms. These gestures would typically show parents I understand how they feel, and I am invested in the health of their child. Hidden behind my mask, face shield, gown, and gloves, I remain a black box. I dispense advice but struggle to convey that it comes from someone who cares.

At the beginning of the pandemic, I would skirt the rules of personal protective equipment (PPE) usage to try and get a moment of human connection. I might appear in the doorway of a patient’s room, smile, and introduce myself before putting on my mask and goggles. If a parent seemed to expect a firm handshake, I would give one, careful to wash my hands before and after. As the guidelines around PPE usage have become more consistent and the danger of the virus increasingly evident, I have cut out these little indulgences. I wear a mask and eye protection from the moment I enter the ED until I leave. I touch as few patients as possible and generally stand 6 feet or more from everyone I talk to.

I believe most providers would agree; these precautions are the only ethical way to see patients during the pandemic. Patients and families are entitled to health care workers who are doing everything they can to protect themselves and those around them. As long as the pandemic lasts, patients and providers will need to recalibrate their expectations of interpersonal interactions. For the time being, good doctors might be defined as much by their PPE adherence as by their ability to connect with patients.

Dr. Shapiro is a clinical instructor of pediatrics at the George Washington University and a clinical associate in the division of emergency medicine at Children’s National Hospital, both in Washington. He said he had no relevant financial disclosures. Email Dr. Shapiro at [email protected].

A punch biopsy of one of the lesions showed a superficial and deep mixed inflammatory cell infiltrate, including neutrophils and eosinophils. There was also vasculitis, karyorrhexis and extravasated red blood cells. The findings are those of leukocytoclastic vasculitis, suggestive of acute hemorrhagic edema of infancy. Direct immunofluorescence was positive for IgM, C3, and fibrinogen, but negative for IgA.

Acute hemorrhagic edema of infancy (AHEI), also known as Finkelstein disease, is form of leukocytoclastic vasculitis that occurs in infants and toddlers aged between4 months and 3 years.

The lesions start as petechiae or edematous, erythematous to violaceous nodules that later coalesce and form “cockade”-like plaques with a central clearing on the face and extremities. Fever and edema accompany the vasculitic lesions, but children do not appear severely ill. Gastrointestinal, renal, and joint involvement are rare.¹ AHEI follows a benign course with resolution of the lesions and symptoms within days to weeks. The etiology of this condition is not known but infection triggers have been reported including coronavirus infections, coxsackie virus infections, Escherichia coli urinary tract infections, herpes simplex virus stomatitis, and pneumococcal bacteremia.^2,3 Our patient had a prior history of pneumococcal pneumonia and metapneumovirus infection. MMR vaccine also has been reported as a possible trigger, as well as some medications.

Laboratory results are usually normal, but some patients may have elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), as noted in our patient, and leukocytosis, thrombocytosis, and eosinophilia. Microscopic analysis demonstrates leukocytoclastic vasculitis of small vessels with associated karyorrhexis and extravasated red blood cells.

The differential diagnosis includes other vasculitic conditions, primarily Henoch-Schönlein purpura (HSP). Patients with HSP tend to be older in age and the lesions described as palpable purpura commonly affect the lower extremities and buttocks. These patients can present with abdominal pain and arthritis; renal compromise also can occur. Direct immunofluorescence can commonly be positive for IgA, which was negative in our patient.

AHEI and HSP are considered different entities, but both present with leukocytoclastic vasculitis.¹ Another condition to consider in patients with fever, rash, and edema is Kawasaki disease, also a form of vasculitis, that affects small- and medium-size muscular vessels with predilection for the coronary arteries. Patients with Kawasaki disease present with fever (usually longer than 5 days), facial and extremity edema (similar to AHEI), skin lesions (which may have multiple presentations, the most common being macular, papular and erythematous, and urticarial eruptions), but also lymphadenopathy and conjunctivitis. These patients appear sicker than children with AHEI. Their laboratory results show leukocytosis, thrombocytosis or thrombocytopenia, elevated inflammatory markers, and sterile pyuria.⁴

Patients with erythema nodosum present with tender erythematous nodules, which can look like early AHEI lesions. The most common location is the lower extremities, but in children erythema nodosum can occur on the face, trunk, and arms. The lesions can occur secondary to infections such as streptococcus, mycoplasma, tuberculosis, coccidioidomycosis, and sarcoidosis, as well as to malignancy or medications. These patients do not appear sick, are not febrile, and are rarely seen under 2 years of age.⁵

Acute febrile neutrophilic dermatosis – Sweets’ syndrome – also should be considered in a patient with tender nodules, fever, and leukocytosis. The skin lesions in Sweets’ syndrome, compared with those in AHEI, are painful and can present as papules, nodules, and bullae on the face and extremities. A prior history of an upper respiratory infection is commonly described in children with Sweets’ syndrome. These patients present with fever, which may start days to weeks prior to the lesions starting. Children with Sweets’ syndrome also can have conjunctivitis, myalgias, polyarthritis, and in severe cases septic shock and multiorgan dysfunction. Sweets’ syndrome can be seen in patients with inflammatory bowel disease, systemic lupus erythematosus, chronic multifocal osteomyelitis, and malignancy; it also may be induced by certain medications.⁶

As mentioned above, the course of AHEI is benign, and the condition resolves within days to weeks. Treatment is supportive.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She had no relevant financial disclosures. Email Dr. Matiz at [email protected].

References

1. F1000Res. 2019;8:1771.

2. Pediatr Dermatol. 2006 Jul-Aug;23(4):361-4.

3. Pediatr Dermatol. 2015 Nov-Dec;32(6):e309-11.

4. Clin Dermatol. 2017 Nov-Dec;35(6):530-40.

5. Yonsei Med J. 2019 Mar;60(3):312-4.

6. Pediatr Dermatol. 2015 Jul-Aug;32(4):437-46.

A punch biopsy of one of the lesions showed a superficial and deep mixed inflammatory cell infiltrate, including neutrophils and eosinophils. There was also vasculitis, karyorrhexis and extravasated red blood cells. The findings are those of leukocytoclastic vasculitis, suggestive of acute hemorrhagic edema of infancy. Direct immunofluorescence was positive for IgM, C3, and fibrinogen, but negative for IgA.

Acute hemorrhagic edema of infancy (AHEI), also known as Finkelstein disease, is form of leukocytoclastic vasculitis that occurs in infants and toddlers aged between4 months and 3 years.

The lesions start as petechiae or edematous, erythematous to violaceous nodules that later coalesce and form “cockade”-like plaques with a central clearing on the face and extremities. Fever and edema accompany the vasculitic lesions, but children do not appear severely ill. Gastrointestinal, renal, and joint involvement are rare.¹ AHEI follows a benign course with resolution of the lesions and symptoms within days to weeks. The etiology of this condition is not known but infection triggers have been reported including coronavirus infections, coxsackie virus infections, Escherichia coli urinary tract infections, herpes simplex virus stomatitis, and pneumococcal bacteremia.^2,3 Our patient had a prior history of pneumococcal pneumonia and metapneumovirus infection. MMR vaccine also has been reported as a possible trigger, as well as some medications.

Laboratory results are usually normal, but some patients may have elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), as noted in our patient, and leukocytosis, thrombocytosis, and eosinophilia. Microscopic analysis demonstrates leukocytoclastic vasculitis of small vessels with associated karyorrhexis and extravasated red blood cells.

The differential diagnosis includes other vasculitic conditions, primarily Henoch-Schönlein purpura (HSP). Patients with HSP tend to be older in age and the lesions described as palpable purpura commonly affect the lower extremities and buttocks. These patients can present with abdominal pain and arthritis; renal compromise also can occur. Direct immunofluorescence can commonly be positive for IgA, which was negative in our patient.

AHEI and HSP are considered different entities, but both present with leukocytoclastic vasculitis.¹ Another condition to consider in patients with fever, rash, and edema is Kawasaki disease, also a form of vasculitis, that affects small- and medium-size muscular vessels with predilection for the coronary arteries. Patients with Kawasaki disease present with fever (usually longer than 5 days), facial and extremity edema (similar to AHEI), skin lesions (which may have multiple presentations, the most common being macular, papular and erythematous, and urticarial eruptions), but also lymphadenopathy and conjunctivitis. These patients appear sicker than children with AHEI. Their laboratory results show leukocytosis, thrombocytosis or thrombocytopenia, elevated inflammatory markers, and sterile pyuria.⁴

Patients with erythema nodosum present with tender erythematous nodules, which can look like early AHEI lesions. The most common location is the lower extremities, but in children erythema nodosum can occur on the face, trunk, and arms. The lesions can occur secondary to infections such as streptococcus, mycoplasma, tuberculosis, coccidioidomycosis, and sarcoidosis, as well as to malignancy or medications. These patients do not appear sick, are not febrile, and are rarely seen under 2 years of age.⁵

Acute febrile neutrophilic dermatosis – Sweets’ syndrome – also should be considered in a patient with tender nodules, fever, and leukocytosis. The skin lesions in Sweets’ syndrome, compared with those in AHEI, are painful and can present as papules, nodules, and bullae on the face and extremities. A prior history of an upper respiratory infection is commonly described in children with Sweets’ syndrome. These patients present with fever, which may start days to weeks prior to the lesions starting. Children with Sweets’ syndrome also can have conjunctivitis, myalgias, polyarthritis, and in severe cases septic shock and multiorgan dysfunction. Sweets’ syndrome can be seen in patients with inflammatory bowel disease, systemic lupus erythematosus, chronic multifocal osteomyelitis, and malignancy; it also may be induced by certain medications.⁶

As mentioned above, the course of AHEI is benign, and the condition resolves within days to weeks. Treatment is supportive.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She had no relevant financial disclosures. Email Dr. Matiz at [email protected].

References

1. F1000Res. 2019;8:1771.

2. Pediatr Dermatol. 2006 Jul-Aug;23(4):361-4.

3. Pediatr Dermatol. 2015 Nov-Dec;32(6):e309-11.

4. Clin Dermatol. 2017 Nov-Dec;35(6):530-40.

5. Yonsei Med J. 2019 Mar;60(3):312-4.

6. Pediatr Dermatol. 2015 Jul-Aug;32(4):437-46.

A punch biopsy of one of the lesions showed a superficial and deep mixed inflammatory cell infiltrate, including neutrophils and eosinophils. There was also vasculitis, karyorrhexis and extravasated red blood cells. The findings are those of leukocytoclastic vasculitis, suggestive of acute hemorrhagic edema of infancy. Direct immunofluorescence was positive for IgM, C3, and fibrinogen, but negative for IgA.

Acute hemorrhagic edema of infancy (AHEI), also known as Finkelstein disease, is form of leukocytoclastic vasculitis that occurs in infants and toddlers aged between4 months and 3 years.

The lesions start as petechiae or edematous, erythematous to violaceous nodules that later coalesce and form “cockade”-like plaques with a central clearing on the face and extremities. Fever and edema accompany the vasculitic lesions, but children do not appear severely ill. Gastrointestinal, renal, and joint involvement are rare.¹ AHEI follows a benign course with resolution of the lesions and symptoms within days to weeks. The etiology of this condition is not known but infection triggers have been reported including coronavirus infections, coxsackie virus infections, Escherichia coli urinary tract infections, herpes simplex virus stomatitis, and pneumococcal bacteremia.^2,3 Our patient had a prior history of pneumococcal pneumonia and metapneumovirus infection. MMR vaccine also has been reported as a possible trigger, as well as some medications.

Laboratory results are usually normal, but some patients may have elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), as noted in our patient, and leukocytosis, thrombocytosis, and eosinophilia. Microscopic analysis demonstrates leukocytoclastic vasculitis of small vessels with associated karyorrhexis and extravasated red blood cells.

The differential diagnosis includes other vasculitic conditions, primarily Henoch-Schönlein purpura (HSP). Patients with HSP tend to be older in age and the lesions described as palpable purpura commonly affect the lower extremities and buttocks. These patients can present with abdominal pain and arthritis; renal compromise also can occur. Direct immunofluorescence can commonly be positive for IgA, which was negative in our patient.

AHEI and HSP are considered different entities, but both present with leukocytoclastic vasculitis.¹ Another condition to consider in patients with fever, rash, and edema is Kawasaki disease, also a form of vasculitis, that affects small- and medium-size muscular vessels with predilection for the coronary arteries. Patients with Kawasaki disease present with fever (usually longer than 5 days), facial and extremity edema (similar to AHEI), skin lesions (which may have multiple presentations, the most common being macular, papular and erythematous, and urticarial eruptions), but also lymphadenopathy and conjunctivitis. These patients appear sicker than children with AHEI. Their laboratory results show leukocytosis, thrombocytosis or thrombocytopenia, elevated inflammatory markers, and sterile pyuria.⁴

Patients with erythema nodosum present with tender erythematous nodules, which can look like early AHEI lesions. The most common location is the lower extremities, but in children erythema nodosum can occur on the face, trunk, and arms. The lesions can occur secondary to infections such as streptococcus, mycoplasma, tuberculosis, coccidioidomycosis, and sarcoidosis, as well as to malignancy or medications. These patients do not appear sick, are not febrile, and are rarely seen under 2 years of age.⁵

Acute febrile neutrophilic dermatosis – Sweets’ syndrome – also should be considered in a patient with tender nodules, fever, and leukocytosis. The skin lesions in Sweets’ syndrome, compared with those in AHEI, are painful and can present as papules, nodules, and bullae on the face and extremities. A prior history of an upper respiratory infection is commonly described in children with Sweets’ syndrome. These patients present with fever, which may start days to weeks prior to the lesions starting. Children with Sweets’ syndrome also can have conjunctivitis, myalgias, polyarthritis, and in severe cases septic shock and multiorgan dysfunction. Sweets’ syndrome can be seen in patients with inflammatory bowel disease, systemic lupus erythematosus, chronic multifocal osteomyelitis, and malignancy; it also may be induced by certain medications.⁶

As mentioned above, the course of AHEI is benign, and the condition resolves within days to weeks. Treatment is supportive.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She had no relevant financial disclosures. Email Dr. Matiz at [email protected].

References

1. F1000Res. 2019;8:1771.

2. Pediatr Dermatol. 2006 Jul-Aug;23(4):361-4.

3. Pediatr Dermatol. 2015 Nov-Dec;32(6):e309-11.

4. Clin Dermatol. 2017 Nov-Dec;35(6):530-40.

5. Yonsei Med J. 2019 Mar;60(3):312-4.

6. Pediatr Dermatol. 2015 Jul-Aug;32(4):437-46.