Although some children are at increased risk for serious illness from SARS-CoV-2, most children are unlikely to become severely ill from coronavirus 2019 (COVID-19).1,2 Also, although most children will not be hospitalized with COVID-19, their health care has still been affected by this pandemic. In this article, Ajanta Patel, MD, MPH (Assistant Professor of Pediatric Pulmonology at The University of Chicago) and Scott Lieberman, MD, PhD (Associate Professor of Pediatric Rheumatology at the University of Iowa), share their perspectives on patient experience and care delivery, future health care encounters, pediatric providers, and potential social implications in the age of COVID-19.
Patient Experience and Care Delivery
Although most children do not become severely ill from COVID-19, their health care experience has been fundamentally altered. Dr. Patel notes that pediatricians have needed alternative ways to connect with their patients in this time of social and physical distancing. Along with other pediatricians, she has shifted most of her outpatient care to telehealth visits. This has been well-received by many families, who appreciate the ability to talk about their child's care while staying safe at home, and without needing to arrange travel, schedules, and childcare. On the other hand, Dr. Lieberman says that he has struggled with “some [telehealth] visits that really need to be in-person so you can examine [the patient].” Specifically, he describes having to choose whether to adjust a patient's medication after concern for worsening symptoms without being able to see the patient in person. It is “not a warm and fuzzy feeling to be treating people without being able to directly monitor their exam,” he says.
Inpatient care has also been severely impacted by this pandemic. Pediatric centers worldwide have been postponing nonurgent inpatient admissions and limiting inpatient visitors to one adult per child.3 Additionally, areas that make a hospital more child-friendly, like playrooms, are now closed at many institutions. “The culture has changed in terms of how people interact,” Dr. Lieberman says. “Everyone walking the halls of the hospital should [now] always be wearing a face shield,” which can increase fear in pediatric patients.
Both Drs. Patel and Lieberman also recognize unanticipated consequences in the inpatient setting due to COVID-19. Early in the course of the pandemic in the United States, especially as the virus reached Chicago, Dr. Patel and her colleagues had an increased focus on COVID-19, particularly in the areas of testing patients with respiratory symptoms and ensuring personal protective equipment (PPE) for the providers. Such heavy attention on COVID-19 may have caused more fear in parents and providers than intended. Dr. Lieberman also expresses concerns about less time being spent with patients in attempts to conserve PPE. At his institution, it was suggested that, when appropriate, “IV [intravenous] pumps may be placed outside of a patient's room,” to decrease the amount of PPE used by nursing staff. However, this scares him a little because providers often “catch clinical changes by actually seeing patients, and this also disrupts the invaluable personal interactions so often provided by nurses when they enter the room.”
Future Health Care Encounters
Like many pediatricians, Dr. Patel and Dr. Lieberman recognize that the decrease in outpatient pediatric visits will affect children's ongoing health care. Preserving vaccination rates and other preventive health practices have become a priority for many pediatricians. As a physician for children who have medically complex or chronic conditions, one of Dr. Patel's biggest concerns is how to care for those patients who are missing appointments and procedures. “We don't have the best way to keep track of these missed appointments and rescheduling, especially if the cancellations were with other subspecialists,” she says. With patients missing so many appointments, Dr. Patel believes that there will be a backlog of elective or non-urgent procedures this fall. Unfortunately, not everything that is pushed back is easy to replace. For example, children with developmental delay are currently unable to receive early intervention services in Illinois as therapists avoid close contact. “When a child misses 4 months of early intervention, that's impactful,” Dr. Patel says.
Although caring for patients continues to be their top priority, physicians also have their own fears. “People are worried about their businesses and practices too,” Dr. Patel says. “Like any business, you have to have customers to stay afloat. Right now, families are appropriately taking safety seriously, but that decreases office visits.” For pediatricians in smaller groups or private practices, the inability to see patients in-person can set them back financially. Many pediatric practices are adjusting workflow to accommodate telehealth to meet patient needs and keep the businesses viable. She notes several institutions are also putting a temporary hold on hiring, which may significantly affect staff well-being and practice growth. Finally, there are many reports of hospital staff, nurses, and physicians being furloughed or given mandatory pay cuts during these tough economic times.
Outside of the clinical setting, both Dr. Patel and Dr. Lieberman predict long-term impacts on children's learning and socializing. “Kids are learning how to deal with not being with their friends, not being at school, and social distancing, which I think for many of them is somewhat isolating,” Dr. Lieberman says. He is also particularly interested in how children will react when they are no longer social distancing. “I wonder for some kids, if it will be a slow return to feeling comfortable being around others again,” Dr. Lieberman says. “We are not going to be isolated until [COVID-19] is completely eliminated,” he says, and the return to some activities while the threat of COVID-19 remains may be anxiety-provoking for some. On the other hand, Dr. Patel addresses the broader changes in our education system. “We are seeing the impacts as we shift to distance learning,” she says, “which is exacerbating educational disparities for those with limited access to technology at home.”
Despite the unique circumstances to which children have had to adapt, both Dr. Patel and Dr. Lieberman are optimistic that this experience will also bring good changes in children's lives. Dr. Patel is hopeful that there will be a “positive impact on hygiene in daycare and school settings” including ingraining the habit of handwashing. Overall, Dr. Lieberman hopes “this will make kids appreciate, at least briefly, general aspects of life, like being able to socialize and be with friends.”
“It's a crazy time to be in medicine,” Dr. Lieberman says, with many changes underway and more on the horizon. However, he reminds us that “kids are amazingly resilient,” and he and Dr. Patel are confident that the pediatric community will continue to adapt as needed to care for their patients.
- Cruz AT, Zeichner SL. COVID-19 in children: initial characterization of the pediatric disease. Pediatrics. 2020;145(6):e20200834. doi:10.1542/peds.2020-0834 [CrossRef] PMID:32179659
- Hasan A, Mehmood N, Fergie J. Coronavirus disease (COVID-19) and pediatric patients: a review of epidemiology, symptomatology, laboratory and imaging results to guide the development of a management algorithm. Cureus. 2020;12(3):e7485. doi:10.7759/cureus.7485 [CrossRef] PMID:32257728
- Sainati L, Biffi A. How we deal with the COVID-19 epidemic in an Italian paediatric onco-haematology clinic located in a region with a high density of cases. Br J Haematol. 2020;189(4):640–642. doi:10.1111/bjh.16699 [CrossRef] PMID:32298461