Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
In part one of a two-part series, AMA Chief Experience Officer Todd Unger talks to pediatricians about the impact of COVID-19 on children, including the latest numbers showing that the number of kids getting COVID is a lot higher than initially anticipated.
Learn more at the AMA COVID-19 resource center.
- Sonja O'Leary, MD, medical director, Denver Health School Based Health Centers
- Stephanie Guarino, MD, MSHP, pediatric hematologist/oncologist, Nemours/Al duPont Hospital for Children
- Greg Blaschke, MD, MPH, pediatrician and professor of pediatrics, OHSU
Unger: Hello, this is the American Medical Association's COVID-19 update. This is part one of a two-part series discussing the impact of COVID-19 on children. I'm joined today by Dr. Stephanie Guarino, a pediatric hematologist-oncologist at Nemours/AI DuPont Hospital for Children and clinical assistant professor of internal medicine and pediatrics at Sidney Kimmel Medical College in Wilmington, Delaware, and Dr. Greg Blaschke, a pediatrician and professor of pediatrics and general pediatrics at Doernbecher Children's Hospital at Oregon Health and Science University in Portland, Oregon, and Dr. Sonja O'Leary president-elect of the American Academy of Pediatrics Council on School Health and a pediatrician, and the medical director of the 18 Denver health school-based health centers in Denver. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. Guarino, We've heard so much about kids and COVID in the news. The latest being that the number of kids getting COVID has been a lot higher than we had initially anticipated. What do you think helped explain this trend, particularly the big numbers that we saw at the end of July?
Dr. Guarino: Well, Todd, I think that what partly explains this trend is an evolving understanding of the presentation of COVID-19 and how it may be different in children, particularly the higher rates of asymptomatic infection in kids.
Dr. Blaschke: And I guess I would add that we've we have seen some increased testing in kids. They didn't really qualify for testing in our community because they were so asymptomatic and/or didn't have moderate or severe disease. And then we also really have opened up across the country. Initially they were all out of school and stuck at home and we've seen more movement and interaction, I think.
Dr. O'Leary: And I agree with both my colleagues. I mean, I think that there's much more capacity to test right now. And there has been so much movement even just like baseball tournaments and kids going back to school so like at university level as well.
Unger: Dr. Blaschke, how has COVID-19, how does it seem to manifest itself differently in children than in adults?
Dr. Blaschke: Well, I think there's so much that we don't know, and we're still learning particularly in kids because we haven't been testing as much as in the adults and haven't been seeing severe disease. So there's a wide variety of ways that it can present, especially in mild forms. And then I know there's some thought about having less ACE receptors in the nasal passageways, but I'm not convinced yet that we really know why it's so different.
Unger: Dr. O'Leary?
Dr. O'Leary: I mean, I agree. I think it's so interesting that the COVID virus just acts so different in children than say flu, where if you look at the flu, it's usually the kiddos who get the infection and then give it to their parents or give it to the adults and this seems to be the other way around. Before we know that our kids were actually getting COVID because of their adult contacts in their home.
Unger: Dr. Guarino, what about the inflammatory symptom that we're seeing?
Dr. Guarino: We actually just spoke about this at our noon conference today at Nemours. And we've seen an increase in cases in this recently. And some of that has been in retrospect, going back and reviewing cases from April and May, even in identifying kids who may have had the multi-system inflammatory syndrome that we didn't realize at the time. I think as our understanding evolves, we will potentially see differences in COVID in children.
Unger: Dr. O'Leary, can we talk a little bit about what the science is suggesting in regard to kids being carriers of COVID-19?
Dr. O'Leary: Yeah, I think there's a couple of articles out there that suggest that kids actually have more viral loads in their nasal pharynx than adults do, but it's not clear to me that they're actually better distributors of the illness. I kind of like to think of them almost like tuberculosis, so when you have a child with tuberculosis, they just don't make the cough enough, like adults do, to spread it to other people. And so I think we're just learning more and more each week as the week passes.
Unger: Dr. Guarino, talk to us about what do you think the biggest challenges are in treating kids and reassuring families during the pandemic? What changes has your practice had to make to help mitigate these concerns?
Dr. Guarino: Well, I think there's been a couple of big changes for us as oncologists. So for kids with cancer who are in the hospital potentially for a month or two at a time, our visitor restrictions have been pretty strict. And so the number of family members at the bedside has been limited. And so the removal of that sort of social support for the patients and the families has had a pretty significant impact. And it's something that we're continuing to manage.
Unger: So those are pretty unique concerns. That's quite a preexisting condition that really could be impacted as well by COVID-19.
Dr. Guarino: And I think in the beginning, we were all really worried about whether this was going to affect our immunocompromised kids a lot more frequently or more severely. And what we've seen over the last few months has been, we've had some cases in kids with oncology diagnoses, both new and preexisting, but it hasn't caused kind of the same severe disease that everybody was worried about. And we're not really sure why that is. I think of it may be that our families are really good at baseline at isolating and masking and cleaning and being more aware of infection risks. And so in that case, that may have served them well. But what we have seen is actually an increase in new diagnoses. We've seen more kids with cancer this year than we have previously, and it's not really clear why that is. Anecdotally, at least we have had some kids who have delayed seeking care because of concerns about the virus. And so that has led to some complications and some bad outcomes.
Unger: Dr. Blaschke, you had to adapt your practice for these concerns.
Dr. Blaschke: Yeah. So I work both in a mother/baby unit or the normal newborn nursery and then in clinic. And so I could speak a little bit to both. In particular, in clinic, I think we initially had to delay care while we responded and trained ourselves and sort of figured out how best to bring families into the clinical environment. I think we also greatly expanded the amount of virtual care that we were doing, both sort of virtual triaged to decide if a child needed to be seen. And then if they really didn't need to be seen at the time, how much could we accomplish over a telehealth or a virtual visit? Those are some of the big things we've seen in clinic. I think with returning or not really, we never left practice, but the amount of face-to-face care has been increasing of late and that we've worked through how to do it safely.
And have had to do a lot of work with reassuring families that we were not having people wait in the waiting room and not ride elevators together, providing all the PPE that both patients, their families and the medical teams needed in order to see them. And then I think up in the nursery, we did some limitations on, for instance, a mother who was laboring could only have one support person present that couldn't swap out. We asked families to stay in their rooms and not really walk in the hallways and those kinds of things. Having a baby is aerosolizing, not really a procedure, but an event that could lead to more transmission. And so again, more PPE and precautions like that.
Unger: Well, thank you so much, Dr. Guarino, Dr. Blaschke, and Dr. O'Leary for being with us here today and sharing your perspectives. That concludes part one of our series. We hope you'll join us tomorrow for part two of our update. In the meantime, for updated resources on COVID-19 visit ama-assn.org/covid-19. Thanks for joining us and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.