doctor's stories

Light at the End of the Tunnel: Overcoming the “MIS-Cellaneous” Clinical Entities of COVID-19

AUTHOR:
John W. Harrington, MD
Director, Division of General Academic Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Harrington JW. Light at the End of the Tunnel: Overcoming the “MIS-Cellaneous” Clinical Entities of COVID-19. Consultant360. Published online March 16, 2021.

 

The Centers for Disease Control and Prevention (CDC) has reported that we can now gather without masks if everyone at the gathering has received both COVID-19 vaccine doses.1 “Finally some respite from mask wearing,” I thought, but this guidance was tempered to the personal home environment vs the health care environment, where masks are still needed. About 10% of the US population is now vaccinated with both doses of the COVID-19 vaccine and 25% has received at least 1 dose, and it appears we are starting to see the light at the end of the proverbial COVID-19 tunnel. However, what has the pandemic wrought for pediatrics and pediatric care providers beyond the 540,000 deaths and multiple hospitalizations of possible parents and grandparents of our children? 

Clinically, we are being inundated with information about the new Kawasaki-like illness called multisystem inflammatory syndrome in children (MIS-C) where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs, and children can rapidly become septic in hours. However, the more common and glaring outcomes I see in practice every day is the discouraging loss of education with the predicted academic drops in reading and math for the most at-risk children and adolescents who live in economically disadvantaged neighborhoods. Next is the increase in mental health referrals, which is overwhelming an already-fragile system. And lastly, but perhaps most distressful to the children, is the rapid weight gain that has occurred from staying home and being sedentary for one year. So, are pediatric providers prepared for these secondary effects as we emerge from the COVID-19 haze in the next 12 months?

In terms of the loss of education and didactics, many schools for our students in under-resourced districts are looking at extending classes into the summer, since a large portion of children initially had trouble using Zoom because of inadequate access to laptops and internet last spring. Now, a year later, these students likely have one parent/guardian who is unable to fully supervise them at home, or the children themselves have become disinterested after winter break, since they are struggling with many other aspects of the social determinants of health like food and housing insecurity. The push to get our students, especially those who live in high-risk poorly performing school districts back into even hybrid classes, has been a monumental challenge. Parents/guardians are still somewhat distrustful that schools can protect their child from COVID-19, and when a vaccine does become available for children, parents/guardians may be even more vaccine hesitant because of this institutional distrust fomented by social media. How will this impact our ability to have a normal school year next fall? The pandemic has also differentially affected children with special needs and disabilities who have individual education plans that cannot be followed virtually, so those children have fallen even further behind. As pediatricians, we are only starting to comprehend the tremendous overall stress on families over the last 12 months through screening.

The impact on the mental health of our children during this pandemic will likely not be fully known for 5 to 10 years. However, currently our screening tools for social determinants of health and depression screening are registering at all-time highs.2 Elementary and early middle school children need that experiential learning and connection with teachers, but they, and especially teenagers, need the socialization aspect of school desperately. Teenagers are feeling socially isolated, and the number of depression screens registering positive, along with suicidal ideation, is increasing at an alarming rate.3 Providing counseling and referral can help, but also getting back to the basics of good sleep hygiene, regular exercise, and making sure there is enough food at home can provide the needed boost to resiliency. However, the comfort food aspect of snacking and eating low-quality and caloric-dense food has increased dramatically, because kids are home and not getting any of their meals through the school.

Reviewing the year-over-year weight of the children being seen in my office has been eye-opening. Weight gain in preadolescent and adolescent patients of 10 and 20 kg is common during their annual well visit. Body mass indexes increasing from normal to obesity spurs discussions of dietary and exercise changes that the parents/guardians admit they likely cannot change. As one mother has stated to me, “They eat and snack all day on chips and junk, and then they play multiplayer video games with their friends when they are not in virtual school.” Unfortunately, the kids knowingly look dejected at the futility of even trying to make the changes. Discussing this dilemma with our endocrinologist reinforced the mother’s recent statistics in the last 6 months, as she noted a 3- to 4-fold increase in both type 1 and type 2 new-onset diabetes.4 Obviously, these new trends have to be addressed, and getting the schools reopened and getting life back to normal will help.    

Pediatric providers, more than ever, will need to advocate for turning this pandemic around and making sure we have the resources and tools to help the families get the runaway train back on track. So, what are the ongoing hurdles we will need to overcome? Schools having trouble restarting, mental health being inundated as families cope, and obesity and diabetes on the rise, as well as any other new “MIS-Cellaneous” clinical entities that we may uncover. These issues and possibly others will all play an important role in how pediatric providers ultimately handle the aftermath of the pandemic. The CDC’s statement has many of us thinking we see a light at the end of the COVID-19 tunnel, but in terms of the physical and mental health of our children, that light may be the oncoming locomotive of health care problems heading our way.

References

  1. Amos A. CDC: quarantining after COVID-19 vaccination is not mandatory. Consultant360. Published online March 10, 2021. https://www.consultant360.com/exclusive/consultant360/cdc-quarantining-after-vaccination-not-mandatory
  2. Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic. Psychol Med. 2021 13:1-9. https://doi.org/10.1017/s0033291720005358
  3. Loades ME, Chatburn E, Higson-Sweeney N, and et al. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59(11):1218-1239. https://doi.org/10.1016/j.jaac.2020.05.009
  4. Khan MA, Moverley Smith JE. "Covibesity," a new pandemic. Obes Med. 2020;19:100282. https://doi.org/10.1016/j.obmed.2020.100282