- Traditional pediatric practices are not the best place for doing COVID-19 screenings
- Most pediatricians should refer children to a local health center, a hospital drive-through or similar venue where they can go through the diagnostic process safely
- Dr. Pasternack has been working with members of the infectious disease team and the Department of Pediatrics to evaluate and adopt treatment plans
- It's still not clear why children have milder cases of COVID-19, though it’s suspected they may have fewer receptors that bind the virus in the airway and in their bodies compared to adults. The inflammatory and immune responses of children may differ from those of adults resulting in milder courses
Much is still unknown about how COVID-19 can affect adult patients. There is even less data on how it affects children. In this Q&A, Mark Pasternack, MD, chief of Pediatric Infectious Disease at MassGeneral Hospital for Children, shares advice to help pediatricians and other physicians navigate the new coronavirus in children.
Q: What should physicians look out for when evaluating children with potential coronavirus infection?
Pasternack: That question is complicated because the evaluation of children for COVID-19 infection carries with it a burden of infection control responsibility. Children need to get a nasal swab for COVID-19 diagnosis and that is an aerosolizing procedure that requires protective gear for the provider.
The traditional pediatric practice is not the best place for doing COVID-19 screening. Most pediatricians should have access to a health center, a hospital drive-through or similar setting where children can be put through the diagnostic process. Many of these facilities require advanced scheduling before the patient’s arrival.
Testing has been restrictive and the recommendations for testing are changing almost daily. As a result, the rules about who is eligible for testing can be a challenge. Testing is primarily reserved for health care workers and for people with known coronavirus exposures. In addition, people living in communities identified as high risk for COVID-19 infection may be eligible for testing even in the absence of symptoms. At Mass General, the testing that's done onsite has now achieved rapid turnaround, so virtually everyone gets their results within 24 hours and typically much sooner.
There are places where it's still a few days or more to get a response. It's a frustrating situation when you can finally get tested then have to wait so long to get the results. So what do you do during that prolonged interval? Providers should advise patients to assume they may be infected and stay isolated.
Q: For children who are diagnosed or suspected of being exposed to coronavirus, are there different treatment protocols from when adults have COVID-19?
Pasternack: This is an area that is a data-free zone, so to speak. I've been working with several members of both my infectious disease team and also the Department of Pediatrics, and we have evaluated and adopted proposed treatment plans based on the guidance prepared by the adult infectious disease group. Although there was some early enthusiasm to consider hydroxychloroquine therapy in children with moderate to severe illness, this is no longer recommended due to a lack of proven effectiveness and risk of serious side effects. The antiviral remdesivir may be available for treating moderate to severe illness in children through compassionate use protocols, but randomized double blind trial data is still not available. These trials have also generally excluded children entirely. Thus, there's really no evidence yet that it's helpful in children, just as there was no clear cut evidence as yet that it's proven to be helpful for adults.
Q: From a viral makeup perspective, do we know if COVID-19 affects children differently?
Pasternack:The physiology in children is largely similar to that in adults. Most viruses only know how to do things one way. The receptors to which the virus binds in adults is thought to be the same receptor to which it binds to in children.
The reason that children generally have more mild cases is not totally clear. It is suspected, although still needs to be proven, that children may have fewer of the receptors that bind the virus in their airway and in their bodies when compared to adults. This theory comes with a precedent. Children may also have an altered inflammatory response when compared to adults. The bacterium, Clostridium difficile, makes a toxin that causes severe gastrointestinal disease in children and adults carrying this bacterium in the intestinal tract. However, with rare exceptions, infants never get symptomatic C. difficile infections. In fact, C. difficile can be cultured out of the stool of many infants and is considered a commonplace occurrence without medical significance. And yet a three-year-old child who gets infected with this germ is likely to get symptomatic diarrhea.
It's thought that the intestine doesn't have the receptor that binds the toxin, thus the disease does not develop. In the same way, the airway of young children may not have much of a density of receptors that bind the COVID-19 virus. Fewer receptors may cause the coronavirus to be less severe in children.
The other possibility, which could exist independently or alongside my first theory, is that the immune response of children may be milder when compared to adults. Individuals who have life-threatening COVID-19 infections seem to have an exuberant and possibly dysregulated immune response, and they develop respiratory failure and require mechanical ventilation because of something that has been labeled a "cytokine storm."
Cytokines are the signaling molecules that the body's immune cells make in various inflammatory and immunological settings. It is suspected that adults who are very, very sick have excessive levels of cytokines in their blood. Children, perhaps, just don't develop cytokine storms following COVID-19 infection as frequently as adults, so they rarely get as severely sick.
Q: Is it possible that the virus could have long-lasting implications that could affect future respiratory care for pediatric patients?
Pasternack: It’s always a theoretical concern, but the lungs of children are generally surprisingly resilient, in part because the lungs of children are still growing organs. Adults have a fixed volume of lung and lose a tiny fraction of healthy lung tissue just through aging, so even healthy elderly individuals have diminished lung reserve. Infants, thankfully, are on top of the slope, so to speak. So if there is lung injury, growing lungs can do a pretty good job of compensating.
There's no proof that COVID-19 causes permanent destruction of lung tissue. But we have seen many other examples of individuals during past respiratory epidemics (like the H1N1 influenza epidemic) or severe respiratory syncytial virus disease that, once they recover, pediatric patients generally do pretty well.
There are exceptions in children with underlying lung disease or a baby who's recovered from a long nursery stay for prematurity and then gets a severe viral illness that might lead to progressive lung damage. But it's not that lung damage is the rule. Our hope is that children who recover, and the vast majority will recover, will do well. We have not yet heard from the Chinese experience or from the European experience about survivors who are left with a chronic pulmonary disability. Whether that becomes clear or not, we'll learn over time.
Q: There's still a lot of research to be done around this, but are there additional resources to share with providers around this topic?
Pasternack: Great question, and obviously the definitive story is yet to be written. But the Centers for Disease Control (CDC) has regularly updated information that is available for both patients and their families, as well as for care providers. The State Department of Public Health similarly has information on its website that covers much of the same ground and is generally consistent with the CDC.
I would say that other organized groups like the American Academy of Pediatrics (AAP) are developing or have developed their best recommendations for diagnosis and management. The AAP has since created a central hub full of advice on treating newborns, clinical recommendations, advocacy and more.
This is a rapidly changing field. But when you bring up the notion of information posted on the Internet, you have to read information from reliable sources. It is important to remind providers and parents that not everything we read on the Internet is valid. Just typing in "COVID-19" on a web browser is not necessarily going to give you the answers that are helpful. I pretty much stand by what the CDC publishes and what the Commonwealth of Massachusetts publishes. The documents on the Mass General website and the above sites are extensively vetted and edited for scientific and medical accuracy.