THURSDAY, March 28, 2024
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For pediatricians, coronavirus raises a thorny problem

For pediatricians, coronavirus raises a thorny problem

Joanna Dolgoff, a pediatrician in Paulding County, Ga., cringed when she saw the photo on Facebook: a crowded high school hallway full of maskless students, an image that quickly went viral. "I was shocked at how closely the kids were packed together and that they weren't wearing masks," she says.

Then it got worse. "I didn't know where the photo was from," she says. The moment she learned these students were from North Paulding High School, where some of her patients attend classes, "I got a sinking feeling in my stomach," she says. "These are my kids. These are the patients I take care of."

As classes resume in person in some parts of the country, pediatricians - like parents, children and teachers - also are feeling the strain of the ongoing pandemic. They must not only provide a safe space to see patients, who range from newborns to 18-year-olds, and ensure a supply of personal protective equipment, but also determine whether that coughing child with a sore throat and fever has a common cold, the flu - or covid-19. 

"We are facing unprecedented challenges as the school year opens, and we're scrambling to figure out how to handle everything," Dolgoff says.

Six students and three staff members from North Paulding High tested positive in the days following widespread circulation of the photo. (For privacy reasons, Dolgoff won't disclose whether any of her patients were among them.) She is angry that young people risk exposure when school districts such as hers fail to follow established public health measures.

"The rule in the county is that you don't have to wear a mask," she says. In addition, she says, the schools are saying they can't social distance because the buildings aren't big enough. "It's not safe to go back to school if they aren't requiring masks, or enforcing social distancing. It's just not safe for the kids, their teachers or the staff."

Parents are in a terrible bind because "they had no choice but to send their kids back to school," she adds. "Most of them had to go back to work and couldn't stay home."

The school year has started in various formats in many parts of the country, making it difficult to protect kids, especially those attending in person. 

"I've been practicing for over 30 years and this spring, summer and fall are not like anything I've ever seen before," says Sara "Sally" Goza, president of the American Academy of Pediatrics, whose website has posted a covid-19 resource page for pediatricians. "We've seen this all across the country. All practices are a little anxious about what will happen in the fall."

Katie Lockwood, a pediatrician with Children's Hospital of Philadelphia, agrees. "Everything has changed," she says. "There's a higher stress level that seems universal and . . . the effects of it are visible. My patients are dealing with food insecurity, job furloughs, challenges of distance learning, loss of family members, missing life events, social isolation and more, which impacts their physical and mental health. This fall, we are facing more unknowns as we enter a new season with covid and the added issue of influenza and other viral illnesses."

Pediatricians are girding for an increase in respiratory illnesses once colder weather sets in. 

"Kids will come in with symptoms - sniffles, a fever, sore throat and cough - that a year ago we would have dismissed as a common cold or flu," Dolgoff says. "Now we have to take it much more seriously. There's no way to tell the difference based on symptoms alone. The only way to know is to test."

When test supplies are limited, "the sickest children will get a test, as well as those who might have been exposed . . . If we don't have enough tests, we treat all possible covid patients as if they have covid," she says.

In the absence of a test, "we have to err on the side of caution and quarantine for 10 days from the onset of symptoms, until the symptoms decrease and there is no fever for 24 hours," she adds, citing guidelines from the Centers for Disease Control and Prevention. "Only patients whose symptoms are not consistent with covid may return to school."

Elizabeth Murray, who practices emergency pediatric medicine at the University of Rochester Medical Center's Golisano Children's Hospital, predicts that local public health officials will be watching disease transmission rates of all common respiratory illnesses closely once all schools open, and likely will advise providers about testing. 

"As pediatricians, we know we will be facing covid-19 in some shape or form, although we don't know how severe it's going to be," she says. "The only certainty is that we are full of uncertainty."

Children represent 9.5% of all cases, with more than 476,439 cases reported since the onset of the epidemic, according to the pediatrics academy. Between July 9 and Aug. 6, pediatric cases rose by 179,000, a 90% increase from the previous total that "caught everyone's eye," Goza says. 

Although most pediatric cases are not severe, and do not require hospitalization, recent research suggests children play a much larger role in community transmission than previously thought, shedding virus for weeks as asymptomatic spreaders. 

"There is risk of infection not just from the symptomatic child, but from asymptomatic children," says Michael Martin, a Vienna, Va., pediatrician and president of the Academy's Virginia chapter. "That is the big unknown."

Moreover, physical symptoms are not the only health issues related to covid-19 that worry pediatricians. Many say they are seeing more mental health problems among their young patients, requiring the intervention of pediatric psychologists. 

"It's rampant around the country," says Dolgoff, a member of the academy's covid-19 task force. "We see anxiety, depression, developmental regression, acting out. They're scared about dying of covid. They're scared about their family dying of covid. They're depressed because they aren't seeing their friends. Younger kids are wetting the bed. Not having a social structure is leading to depression in children."

Martin agrees, noting that typical childhood stresses usually ease in the summer "as kids are able to unwind at camps and during family trips," he says. "This did not happen this year."

Still, after a drop in the spring, children are returning to pediatric offices for checkups, immunizations and sports physicals. At the start of the pandemic, when many people shunned doctor visits, some offices were forced to furlough staff members they couldn't pay. Visits still may decrease in areas with virtual learning, since children isolated at home are less likely to get sick - a good thing for public health, although less so for pediatric business.

"No one wants children getting ill with ear infections, colds or the flu, so fewer sick children would be great," says Gary Bergman, a pediatrician who practices in Alexandria and Fairfax, Va. "But as a business owner, I also have a responsibility to my staff - and their families - to keep them employed."

When the pandemic began, Bergman says, visits to his office dropped by half. Now they are rising again. 

"Our numbers have rebounded, but not all the way to pre-pandemic numbers," he says. "It appears parents are finally starting to feel more comfortable coming into a medical office, especially for delayed checkups and overdue vaccinations."

When patients and children return, they will find waiting rooms looking very different. Children no longer sprawl on the floor, playing with toys or with each other. Parents no longer sit and chat. Instead, they sit in their cars and wait for a call telling them a room is available. Once inside, there is little, if any, wait time. Everyone must wear a mask. Chairs are stacked, or stored. There are no toys, books or magazines. Practices clean and disinfect each room between patients. Doctors and staff all wear PPE, a sight increasingly familiar to young patients.

"Children have been very tolerant of my PPE," Lockwood says. "Sometimes I don't recognize my colleagues under our PPE, but the children don't seem fazed. If a patient does look hesitant, I try to make a joke about my 'superhero mask' or 'bug-eyed goggles.' "

While protecting patients, pediatricians also must remember to protect themselves, Martin says. "We have experience mitigating this risk," he says. "Many of us have continued to practice throughout the pandemic without getting ill. We have learned that the risk of infection stems from letting our guard down with each other, and taking masks off in lunchrooms and common areas, and not social distancing with peers when we should."

To be sure, the pressures are great, but pediatricians are adjusting, Goza says. "It's amazing how practices are adapting," she says. "They are making it work."

 

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