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CONTENTS OF THIS ISSUE

Winter 2021 Issue

Volume 13 | Number 1

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Coronavirus and the Pediatrician

Stan Grogg, DO, FACOP, FAAP               
Contact information: Stanley.Grogg@okstate.edu

Dr. Grogg

Stan Grogg, DO, FACOP, FAAP

Background
On March 11, 2020, the World Health Organization (WHO) classified the COVID-19 (coronavirus disease 2019), a pandemic, defined as epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people (1) . One hundred and fourteen countries had reported that 118,000 have contracted Covid-19, also known as SARS-CoV2. Nearly 4,300 people have died (2). Most theme parks, several restaurants, movie theatres, and other entertainment centers have closed until the pandemic has been contained. Travel internationally has been restricted to help control the spread of COVID-19. (3, 4)

On Monday, March 9, President Trump recommended that Americans should avoid “discretionary travel’’ for the next 15 days as part of new Centers for Disease Control and Prevention guidelines announced to blunt the spread of the virus. March11, (6) the World’s Health Organization, WHO, declared the coronavirus as a pandemic. (5) On March 16, 2020, President Trump outlined new guidelines for the United States of America (Figure 1).

Fig 1
Fig.1 President Trump’s Guidelines

Incidence COVID-19 Children
Interestingly, initial Chinese studies published in the Journal of Pediatrics, suggest pediatric patients do not seem to be as high a risk as adults and people over 50 years of age. (8) As of February 20, 2020, 2.4% of the 75,465 cases (confirmed and suspected) in China had occurred among persons younger than 19 years old. Similarly, with Severe Acute Respiratory Syndrome (SARS) epidemic in 2002-2003, also a Coronavirus, less than 5% of cases were diagnosed in patients younger than 18. CDC states that it is “unknown if differences in reported incidence of confirmed COVID-19 among children versus adults in China is because of difference in exposures (e.g., children are less likely to care for sick contacts), disease severity, testing, or surveillance (e.g., symptoms at presentation differ from case definitions for surveillance or diagnosis). (9)

Symptoms and Complications in Children: (Figure 2)
In nine hospitalized infants in China with confirmed COVID-19, only half presented with fever. One child had primarily gastrointestinal symptoms of vomiting, diarrhea, and anorexia at initial presentation. There are multiple reports to date of children with asymptomatic SARS-CoV-2 infection. Data from pediatric cases of SARS also show milder symptoms among children compared with adults, and adolescents with SARS had more severe symptoms compared with younger children. (9)

Fig 2
Fig. 2 Symptoms

Children seem to have rare complications from COVID-19. As of February 20, 2020, just one of the 2,114 deaths among 55,924 confirmed COVID-19 cases in China occurred among children younger than 20 years old. Chest X-rays of children with COVID-19 show patchy infiltrates consistent with viral pneumonia. (9)

Treatment
Currently, there are no antiviral drugs recommended or licensed by the U.S. Food and Drug Administration (FDA) for COVID-19. Clinical management includes promptly using recommended infection prevention and control measures (e.g., a respirator or facemask, gloves, gown, eye protection) in healthcare settings and supportive management of complications. (9)

Answering parents’ questions
The New York Times posted an article March 18, 2020, by Jessica Grose with consultants.

Taking children to public places and functions
Practice social distancing, which means sticking close to home and avoiding large groups of people such as food courts, restaurants and groups of more than 10 people. Remember the Coronavirus is reported to last for several hours in aerosols and on surfaces, according to a new study from National Institutes of Health, CDC, UCLA and Princeton University, was detectable in aerosols for up to three hours, up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel. The results suggest that people may acquire the virus through the air and after touching contaminated objects. (11)

Hand sanitizer
Most infectious disease experts do not recommend making your own hand sanitizers. A hand sanitizer should have greater than 60 % alcohol. Example of greater than 60% hand sanitizer are Purell and Highmark. Hand sanitizers should only be used if soap and water are not available.

Cold or flu-like illness
For a young child with a runny nose, low grade fever, cough and sore throat, what should the parent do? Before going to a pediatrician’s office, a parent should call for advice. With so many respiratory diseases in communities, it is best to call the pediatricians office for advice rather than expose the child to other illnesses. If the child develops more severe symptoms, such as trouble breathing, an inability to eat or drink or a change in behavior, an office visit is indicated.

Which children should be tested for Coronavirus?
Unless the child has a history of direct contact with someone who has tested positive for the virus, a history of travel to affected areas or is sick enough to be hospitalized, it is unlikely testing will be conducted. Older and higher-risk patients are being prioritized for testing because they tend to develop the most severe symptoms after infection.

Well child checkups
Because of the COVID-19 pandemic, the benefit of attending a well visit and receiving necessary immunizations and screenings should be balanced with the risk of exposure to other children and adults with potential contagious disease.

According to the Ameriucan Academy of Pediatrics (AAP), options for pediatrician might include: (12)

Use of public transportation
Only use as last resort during a Coronavirus epidemic.

A child with asthma
Presently there is no evidence that children with asthma are at an increased risk of complications from COVID-19.

Hygienic recommendations
In addition to washing hands frequently, caretakers should wash bedsheets, towels, stuffed animals in hot water more frequently. Clean hard toys with antibacterial wipes regularly — particularly after outdoor use.

Grandparents’ visitations
Adults older than 60 years of age seem more likely to develop complications from the coronavirus and because children can carry coronavirus without symptoms, grandparents, in general, should not visit grandchildren.

Newborns
There is little data about newborns currently. One should wash hands before handling an infant and avoid taking newborns to crowded places.

Traveling with Children during a Coronavirus epidemic
Travel plans by pediatricians, their families and their patients may have been significantly altered because of the Coronavirus contagiousness. Most of the larger children's vacation areas closed. On March 12, 2020 Disney Corporation announced the closing of all their theme parks and cruises. (13). The Japanese 2020 Summer Olympics are delayed. As of March 24, 2020, 158 million Americans have been “told to stay home by their local and state governments” according to an article in the New York Times. (14). Certainly, international travel has been limited by closed borders.

The nearly two-hour coronavirus briefing on March 23, 2020, hinted that the economic shutdown meant to halt the spread of the virus across the country would not be extended. “Our country wasn’t built to be shut down,” the President said. “America will again and soon be open for business”. The following day, Newsmax TV reported that “Trump is scaling back social distancing guidelines”. (15)

Traveling healthy with Children
When facilities and travel reopen, the pediatrician should be ready to suggest to parents things to do to prevent infectious diseases. First and foremost, all children should be up to date on their immunizations. The 2020 vaccine schedule should be reviewed, and families requested to have their children up to date.

A practical article by the “traveling mamas.” http://travelingmamas.com/, can be utilized by families and parents to read prior to traveling with children.(17) The article cites the following recommendations for staying healthy while traveling with kids!

1. Keep hands clean.
2. Use antibacterial wipes.
3. Avoid germs, allergens, and air pollution with a Bioscarf or Biogaiter.(fashionable facemask)
4. Make smart food choices.
5. Take vitamins and supplements.
6. Maintain good sleep habits.
7. Stay hydrated and stick to safe beverages.
8. Protect your family from bug bites.
9. Apply sunblock.
10. Avoid or handle motion sickness.
11. Keep a separate stash of medicines just for travel.
12. Take it easy.

Flying
An article published on Healthline by Heather Grey on February 24, 2020, discusses how people can help protect themselves from illnesses while flying. (18). The recommendations can be utilized when flying with children.

Take at least one N-95 facemask per person. If someone is traveling close to you with a runny nose and cough, put on the N-95 face mask. Make sure you pinch the metal at the top of the mask to cover the nose. Wash your hands with soap and water or hand sanitizer with more than 60% alcohol concentration, before putting on the mask. Do not touch the mask after adjusting for your face. (Fig 3)

Fig 3
Fig. 3. Barbara Grogg, Disinfecting airplane seat area.

Cruising
Presently all cruise lines have shutdown but hopefully, they will become operational in the summer. Dr. William Schaffner, an infectious diseases specialist at the Vanderbilt University Medical Center in Nashville, told Healthline, “Cruising to South America? Cruising the Caribbean? Cruising the Mediterranean? No problem, at least not from the point of view of coronavirus, but Southeast Asia cruising? Maybe next year.”

When cruising, the most frequently reported cruise ship outbreaks involve respiratory infections, GI infections (such as norovirus), and vaccine-preventable diseases other than influenza, such as varicella (chickenpox). It is important to use the cruise ships sanitizers frequently and wash the hands with soap and water before each meal and on the way out of the dining areas. (19)

Air Filtering Systems (planes/cruise ships) 
It’s standard practice for the air conditioning systems of cruise ships to mix outside air with inside air to save energy. The problem is that these systems can’t filter out particles smaller than 5,000 nanometers,” said Qingyan Chen, PhD, professor of mechanical engineering at Purdue University, reported in Healthline. “If the coronavirus is about the same size as SARS, which is 120 nanometers in diameter, then the air conditioning system would be carrying the virus to every cabin”. (18)

Planes have more effective air filtration systems, but travelers who are sitting close to a coughing or sneezing passenger may still be exposed to airborne germs. (18) If you are worried about contracting a respiratory infection from another passenger, wearing a face mask may help lower the risk.

Conclusions
Pediatricians are frontline healthcare providers. The Coronavirus epidemic has resulted in a total disruption of our primary care practices. President Trump announced on 3/24/2020 that he hopes to have the United States of America out of lockdowns and social distancing by Easter, April 12, 2020. With research for the development of new pharmaceutical agents to treat and prophylaxis for patients and the vaccine development in 12-18 months, our patients will be ready to resume playdates, enjoy the parks and to travel again.

References: All references were looked at on 3/24/2020

  1. WHO classifies COVID-19 as pandemic: https://ourworldindata.org/coronavirus (reviewed 3/16/2020).
  2. COVID-19 outbreaks:  https://www.statnews.com/2020/03/11/who-declares-the-coronavirus-outbreak-a-pandemic/
  3. Theme parks closing: https://insidethemagic.net/2020/03/us-theme-parks-closed-coronavirus-tm1/
  4. Schools closing in USA: https://insidethemagic.net/2020/03/us-theme-parks-closed-coronavirus-tm1/
  5. President Trump’s travel guidelines: https://www.factcheck.org/2020/03/the-facts-on-trumps-travel-restrictions/
  6. WHO calls Coronavirus a pandemic: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
  7. President Trump issues new guidelines for Coronavirus: https://www.whitehouse.gov/wp-content/uploads/2020/03/03.16.20_coronavirus-guidance_8.5x11_315PM.pdf
  8. China study for children Peds: https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf
  9. CDC site for pediatricians: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html
  10. New York Times, questions parents might ask: https://www.nytimes.com/2020/03/09/parenting/coronavirus-parents-need-to-know.html
  11. How long does COVID-9 last on surfaceshttps://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces
  12. Academy of Pediatrics (AAP) well-checkup during coronavirus and influenza epidemics: https://services.aap.org/en/pages/covid-19-clinical-guidance-q-a/.
  13. Disney properties are closed: https://www.nytimes.com/2020/03/12/business/disneyland-coronavirus.html
  14. 158 million Americans told to stay home. https://www.nytimes.com/2020/03/23/world/coronavirus-updates-usa-world.html
  15. Trump weighs scaling back social distancing guidelines: www.Newsmax.com.
  16. AAP recommendations for immunizations: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/Pages/Immunization-Schedule.aspx
  17. The traveling mamas, traveling with kids: https://travelmamas.com/how-to-stay-healthy-traveling-kids/.
  18. Traveling during respiratory outbreaks: https://www.healthline.com/health-news/how-to-protect-yourself-while-traveling-during-the-coronavirus-outbreak
  19. Common diseases on cruise ships: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/cruise-ship-travel
  20. President Trump hopes to have no lockdowns by April,12, Easter. https://www.washingtonpost.com/world/2020/03/24/coronavirus-latest-news/

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