Reports of a local cluster related to youth sports activities hit the news just days after the University of Kansas Health System confirmed a pediatric patient died of COVID-19 last week.
While pediatric COVID cases remain low, we reached out to Newman Regional Health’s Chief of Pediatrics Dr. Derek Brown about what types of COVID-related infections that have been seen in children.
Brown said most children who get infected with COVID-19 do not get as sick as adults. Even children who are experiencing active infections may not experience many symptoms.
But, in rare cases, children diagnosed with COVID-19 have developed an inflammatory syndrome that is associated with a number of serious and potentially life-threatening complications.
“MIS-C is an acronym that stands for Multi-system Inflammatory Syndrome in Children,” Brown said. “MIS-C is a complex disease associated with COVID-19 summarized as a condition where different body parts that can become inflamed, including the heart, lungs, brain, kidneys, eyes, skin, or gastrointestinal organs such as the stomach and/or intestines. Medical experts do not know what causes MIS-C, but it has been identified in the presence of COVID-19 virus found in the child’s system or had been around someone with COVID-19.”
Brown said the Centers for Disease Control states that MIS-C typically presents in an children younger than 21 years of age, with fevers greater than 101 degrees lasting more than 24 hours. Those patients have some type of inflammatory finding of certain body parts or organ systems which have been ruled out from other inflammatory type syndromes or diseases such as Kawasaki’s Disease.
Symptoms of MIS-C include fever, abdominal pain, vomiting, diarrhea, neck pain, muscle aches, rash, bloodshot eyes, inflamed lips, fatigue, swollen lymph nodes and swollen extremities.
Brown said children with MIS-C generally do not have the respiratory symptoms typical of COVID-19. They do, however, have a high association of cardiac-related issues such as enlargements or aneurysms of coronary arteries. Excessive clotting problems such as pulmonary embolisms and deep vein thrombosis has been noted.
“Usually these children end up in the emergency room, and are diagnosed after doctors may do certain tests to look for inflammation or other signs of disease,” Brown said. “These tests might include: blood tests, a chest x-ray, a heart ultrasound (echocardiogram), and/or an abdominal ultrasound. Physicians may provide supportive care and may use medicines to treat inflammation and swelling. Most children who become ill with MIS-C will need to be treated in the hospital and some will need to be treated in the pediatric intensive care unit (PICU).”
“MIS-C is very rare,” Brown said. “Usually, most of the ages that we see with MIS-C are in children usually between 1 and 14 years of age — 91% — with only about 5% of the cases occurring under the age of 1. The average age is 8 years old.”
While MIS-C is a serious condition — and potentially fatal — pediatricians say most children who were diagnosed with the condition have improved with medical care.
“While the symptoms are sometimes varied, the patients who came to St. Louis Children’s were successfully treated and went home well after about two weeks in the ICU,” Dr. Patrick Reich, medical director of infection prevention at St. Louis Children’s Hospital, said. “But the medical community is still learning about MIS-C.”
And, it’s rare.
As of July 15, there had been 342 known cases of MIS-C in the United States and six related deaths.
“Between Kansas and Missouri, there might be no more than 20 cases — so it’s rare,” Brown said.
Race and ethnic breakdown
Brown said male patients have a higher likelihood of developing MIS-C, at 55%. In terms of race and ethnicity MIS-C also falls along the breakdown of individuals with COVID-19. Hispanics tend to be the most likely individuals having the disease at 38%, with non-Hispanic Blacks at 33% and non-Hispanic whites identified at 15%.
So, why does COVID-19 tend to affect Hispanic and Black populations more often?
“Typically, Hispanics and African-Americans are in ‘essential’ jobs and are in direct-line exposure with individuals who might be ill with little to no protection from COVID-19 — what one could be considered to be ‘in the front lines,” Brown said. “Many of such jobs result in contact exposures with the inability to be 6-feet apart and not being able to break away for 10-minute intervals of time. There is more of a likelihood of being exposed to the coronavirus because of their ‘essential’ job profile.”
Brown said other factors have been noted by White House Coronavirus Task Force Member Dr. Anthony Fauci, regarding multiple co-morbidities — or health issues — in those populations.
“A number of Hispanics as well as African-Americans tend to have multiple co-morbidities — meaning they have more health issues, problems with diabetes, asthma, heart issues — and they tend to be the COVID-19 patients who have more symptoms and more likely to be tested,” Brown said. “With all this in mind, the symptoms tend to be more overt in African-American and Latino/Hispanics than in other ethnic or racial populations, but that’s the answer that they have given thus far. There’s still a lot to learn from this disease, and the numbers favoring Black and Hispanic populations may be initially skewed since the study of the coronavirus and its complications are in its infancy and the numbers of cases may change over time.”
Brown said the long-term effects of MIS-C related to COVID-19 are not entirely clear.
“Due to the ‘newness’ of the disease, it is unclear of true long-term effects from COVID-19,” he said. “Due to the presence of cardiac issue involved, coronary aneurysms would be a concern resulting in echocardiograms to be performed on a regular basis as seen in Kawasaki’s Disease to make sure that there’s not any concerns which may be performed in the first four to five days of diagnosis as well as repeated four to six weeks later. Follow-up echocardiograms could be performed annually or biannually depending on its severity. So, I think that since this is also very new, it’s going to be hard to really discern down the road what other concerns or complications might come from this illness.”
Patients have been seen with renal — or kidney — problems, some even ending up on dialysis. About 30% of patients that have been hospitalized with COVID in China and New York developed moderate to severe kidney injuries, Brown said.
“The kidney damage is, in some cases, severe enough to require dialysis,” he said. “Some hospitals experiencing surges of patients who are very ill with COVID-19 have reported they are running short on the machines and sterile fluids needed to perform these kidney procedures. So I think our breadth of understanding of COVID-19 and its complications are currently in its infancy. I think it’s something that we will have to deal with head on in the coming months and years as it continues to unfold.”
As schools begin to lay out plans for the upcoming school year, Brown said there are no easy answers. As a pediatrician, he would recommend a hybrid experience for children starting out — as well as social distancing and mask wearing when possible in face-to-face situations.
“As a pediatrician and advocate of the American Academy of Pediatrics, I would follow recommendations of initially going to a few days a week to minimize congestion and in schools with limited space, and maybe stress part of the education can be done online virtually,” Brown said. “Having appropriate spacing and wearing masks is key. Not politics, just science. I think it’s going to be challenging. I think it is important for schools to be flexible and have goals to adjust based on the level of viral transmission in the school and throughout the community in September.
As noted by the AAP policy, the school environment should be ‘practical, visible and appropriate for child and adolescent’s developmental stage.’ Special considerations should be made for vulnerable individuals that are medically fragile and have developmental challenges with the goal of a safe return to school. No child or adolescent should be excluded from school unless required because of unique medical needs or to adhere to local public health mandates. As supported by the AAP, it is important that pediatricians, families and schools should partner together to collaboratively identify and develop accommodations when needed.”
Brown stressed that while it’s important for children to go back to school, it needs to be done in a way that’s safe and productive for everyone.
“We also want to make sure that the teachers are safe as well,” he said. “So it has to be a decision across the board. There are a lot of unclear pieces we need to put together to provide a safe and protected place to interact, study, and learn.”
Focus on the science
While those plans are being made, Brown said it’s important to listen to those on the front lines — not politicians.
“I do think that it’s very important that our country gets back to an economy that is successful and thriving, but at the same time, it needs to be done in a safe and pragmatic way,” he said. “To get lost in the politics of it, is just making the issue much more convoluted and obtuse and the problem is that we need to really focus on how as a nation, we can do what’s best for the community and not for the individual. I think at Newman Regional Health, we’re really trying our best to protect our patients, protect the community, and create a positive message for the community to socially distance, wear masks and to do what’s medically prudent for Emporia and Lyon County, so hopefully the politics can be pushed to the side and just deal with infection at large.”