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  • Writer's pictureDr. Bow Tie

COVID-19 and Vaccines: Masking Guidelines Update, Additional Points from a Pediatrics View on MIS-C

One of the best things about being in scientific circles and having come through premedical and medical training is that I have the privilege of knowing smart people who are willing to share their knowledge alongside and even more in-depth than my own. I am an adult hospitalist with board certification in internal medicine. But my latest posts have predominantly discussed children and adolescents, so it helps to get input from those who actually work in pediatrics. When I posted this on Facebook, I was joined by my former classmates, Heather Rodman (a PharmD who now works as a Clinical Pediatric Specialist) and Arthur Chang (a Pediatric Infectious Disease fellow who we've heard from before nearly a year ago) to supply some additional information about pediatric implications of COVID-19.


Heather: I would also like to remind people of [Multi-system Inflammatory Syndrome in Children] (MIS-C) due to COVID-19. Joe if you need info on it the primary guidelines are by the College of Rheum. That’s more our serious issue with peds than PASC in my clinical opinion. CHOP and one of the other top Children’s hospitals (check Seattle, Colorado, Boston) also have pretty good publicly available protocols.

I usually see at least one per week at a non major referral center for pediatric patients. Sometimes more, usually 2-4wk post an active COVID-19 uptick in adults. This was certainly even more prevalent when I worked at Cincinnati Children’s since it is a top children’s center.

Some require [vasopressor medications] temporarily due to hypotension. Some have EF in the 30s on ECHO. It truly is very much like Kawasaki’s Disease. And it can be bad.

And much like Kawasaki’s Disease, except without knowledge of truly how the long term effects may be, it has the potential for the heart and circulatory issues to be permanent in the mod-severe cases. In general my experience is actually that active COVID-19 truly isn’t so bad in kids in the majority of cases. It’s the MIS-C that comes after and can be a diagnosis that comes 2 to upwards of 6-8wk after even unknown, asymptomatic COVID in a child. Many of the cases I’ve personally observed - the parents didn’t even know the child had COVID-19 but they often (not always) knew they had been exposed.

This does come with the caveat that certain strains that are more recent or may start to circulate could potentially change that.

For pediatrics AAP is certainly a top resource as well as if CDC has child-specific pull out data which it will sometimes do.

You can see here that the percentage of cases represented by children has gone up. Hospitalization and overall mortality is still low (though not 0). Again, however the MIS-C is considered a separate post-COVID-19 diagnosis. This is official data however I believe this personally to be under reported. Unless a diagnosis code at a hospital auto-forces a generated report to CDC I would argue that the many cases aren’t getting sent to any level of public health reporting if that requires a doc to manually fill in and send something. However again I am still including said public data in case my bias is affecting my thoughts on where statistics actually are with MIS-C.

I have been on what I feel like is a forgotten island since COVID-19 began as a pediatric clinical specialist. It’s almost like the public can only handle so much terrible plague and potentially apocalyptic-style info for their brains...so lets not add in the scary stuff about kids. And here I am taking care of kids where parents are just like I wish I would’ve known, I would have cared more about them wearing their masks, etc., etc.

Pediatrics has been a complete and utter oversight in the national AND worldwide response and discussion of this pandemic. And it’s been so frustrating.

Take home points for anyone reading: 1. Children may be “less” effected by COVID-19 active disease, but that does not mean no risk.

2. A primary and unique concern that adults do not experience is the post-active disease inflammation syndrome (MIS-C) and how that can be quite serious with potential long term effects on the heart. This can happen in children who carried asymptomatic disease.


Arthur:

I'd echo what Heather was saying. We've consistently seen spikes of MIS-C with the recent waves of COVID-19 in Buffalo and we're in line (slightly better numbers wise) than the rest of country / world with roughly half of kids with MIS-C coming in with low blood pressures requiring support [in the most extreme cases heart/lung bypass aka ECMO]. It really has broken the conventional wisdom in pediatrics that "kids don't come in with [primary] cardiac failure" Certainly we're keeping an eye on it and Buffalo is part of a multinational collaborative studying this condition so hopefully we'll continue to have a better understanding of it as time goes on. My only minor comment on the Kawasaki front (I have to as a person who had Kawasaki and now is a researcher in Kawasaki and MIS-C), is that the current body of evidence is that these are two separate phenomena. But the other points about long term sequelae are entirely well taken and those studies are being done now.

I'd also echo the professional societies / CDC reporting on adolescents. This last wave we've had a decent number of adolescents requiring admission for acute COVID-19.

I'll also take a little time and put my two cents about a slight aside before I take the rest of my day off...we're seeing a ridiculous amount of diseases that should not be cropping up. But because public health resources are being stretched thin, access to care during a pandemic, and general long term issues about how healthcare interfaces with American society has only widened this problem. The NYS DOH just issued a health alert about a rise in congenital syphilis, a condition normally prevented with a couple of shots of penicillin. I've seen more advanced tuberculosis and HIV/AIDS than I care to see too. All of which is frustrating because they're preventable.


Heather: Oh my gosh yes! Agree with you on all that you said whole heartedly.

And certainly KD and MIS-C are still separate diagnoses so I wouldn’t want anyone to be confused about that. I only mention it because it seems to be a way for people with less pediatric knowledge to instantly understand the overall clinical picture and treatment modalities a little more without having to discuss in detail. Different diseases with different cause and unknown long term effects with MIS-C, but somewhat similar picture (to the point that diagnosis between the 2 can be difficult at times) and similar treatment options thus far. Things have changed as we’ve researched too. For example I know we used to mock KD aspirin dosing but now with MIS-C we promote upper dose limit of 81mg (generally avoid the KD high dose strategy that we DID follow earlier in 2020). So i’m with you on that.

As for other diseases affecting neonates - adolescents, also agree! So much in regards to preventable diseases, lower quality of care for chronic disease (such as asthma), and issues of neglect (such as incr. accidental ingestions) or direct psych issues in the pediatric patients themselves moreso our adolescents. This is all my personal observation but man the amount of times I ran to trauma pages for toddlers getting into narcotics from relapsing parents earlier in 2020 was insane in itself.


Me: Thanks, as usual, for your insights, too, Arthur. And I can feel your frustration, just like I feel Heather's. 3M recently released its “State of Science” report and it said that skepticism of science is lower than it has been but it sure doesn’t feel that way these days. Outbreaks of once-nearly-eradicated diseases, disbelief in what were thought to be easy-to-use protective measures. Scientific communication needs to step its game up, badly, but sometimes there is just too much to address.


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