Strategizing pediatric healthcare preparedness for the second wave of the COVID-19 pandemic
Though the COVID-19 pandemic has had a relatively low impact on the pediatric population so far, it is feared that the second wave, which is already underway in many parts of the world, may take its toll on the young and old during the winter season.
An article published in October 2020 in the journal Frontiers in Pediatrics discussed a strategy that may help differentiate cases of COVID-19 from other common respiratory infections in winter.
The paper, put together by a team of scientists based in the United Kingdom and Italy, also underscored the need for healthcare policies to account for the very real possibility of inadequate protective personal equipment (PPE), staff and hospital capacity, aggravated by the increased number of pediatric infections.
By way of solution, the paper described the role of a unified plan that includes widening the reach of vaccination, changing around the organization of school services, putting in place smooth transitions between home, outpatient and hospital services, and maximizing the potential of telemedicine, to cope with these challenges.
Fewer children by far have been visiting pediatricians, partly due to restrictions on social interactions. At the same time these pandemic-related restrictions have prevented child infections from circulating.
However, in the coming winter, constant vigilance will be required to recognize the onset of a new wave of COVID-19 infections. This may be quite different from the situation during the first wave since at that time, the cold season was half over, and both flu and bronchiolitis were slowing down. The closure of schools also had an enormous impact on the rate of other pediatric infections.
A French study showed that gastroenteritis, common cold, and acute otitis media declined in incidence by a whopping 70%, and bronchiolitis by around 64%, following school closures. This was accompanied by a corresponding decrease in the number of pediatric visits to the emergency department and an approximate 45% fall in pediatric hospitalizations.
In contrast, during the coming winter, many regions will have children attending schools again, with flu, whooping cough, respiratory syncytial virus (RSV) – not to mention bacterial diseases like pneumococcal and meningococcal infections, gastroenteritis, and streptococcal infections, making the rounds as usual. These will eat up both consulting time (since they may resemble COVID-19 in many cases) and other resources (since COVID-19 must be excluded before these children can be treated in a normal setting).
The axiom that prevention is better than cure is unquestionably relevant in this situation, as extensive vaccination is the best, fastest, and easiest way to ensure that many pediatric infections never happen at all. This is especially valid for very young babies and children who often need to be hospitalized with the flu or RSV.
The authors stressed the need for the broadest possible coverage of preventable diseases, especially the flu, non-mandatory illnesses like measles and mumps and pneumococcal pneumonia, to avoid unnecessary strain on pediatric healthcare systems.
The incentive for achieving this is the unacceptable alternative: if every child with suspicious symptoms has to be tested until found COVID-19 negative, the patient flow in emergency departments and wards will back up, leading to delays in treatment at all levels, which itself reduces the quality of care. Thus, constant efforts to achieve the highest possible immunization efforts will be required, exploiting every opportunity and every medium that can pass on the appropriate message while allowing interaction.
This strategy is neither “novel” nor “innovative,” the authors emphasized, and should therefore not cost much to implement.
Children seem to be more resistant to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus than other age groups. On average, they also have more straightforward or milder courses of the disease once infected. Moreover, many educational experts and parents believe that education is not delivered adequately unless the child attends school: a tenet which is disputable, judging by the experience of many millions of home-instructed children. However, if schools are reopened before the pandemic is brought under control, communicable disease rates will once again soar.
To utilize the light that has been shed on the circulation of infectious diseases among children in classrooms and in common dining rooms at school, the authors have recommended making school reorganization a priority for policymakers. Some of their recommendations include physical distancing within the classroom by at least 1 meter, sanitizers at the door of each classroom, fewer students per class and a lower student to teacher ratio.
For school doctors or nurses to catch early infections of any sort and ensure proper immunizations are also considered a sound objective. School reorganization is likely to be the weak spot in the overall strategy, requiring massive financial and logistical support. The authors say: “It is likely underlying inequities will be exacerbated with the most deprived settings likely to be disproportionately affected,” unless, of course, the government steps in to assure that all schools are adequately funded and staffed to meet the above guidelines.
With the need to resume routine outpatient pediatric healthcare services to some extent, pediatricians will have to prepare to rule out COVID-19 in every child with similar symptoms, and probably to screen the parents as well. This can be met only by reorganizing health plans concerning the schedule of outpatient follow-up visits, and educating caregivers about fever in children, its management and danger signs, as well as using technology to avoid unnecessary clinical visits while allowing appropriate emergency department visits without restriction.
Telemedicine as a first contact with a sick child should become a norm as it allows medical history to be taken into account and the child’s behavior to be assessed. This can help medical professionals decide if the child should be seen in person or cared for at home with a follow-up after a specified time, within 24 hours.
If the former, all necessary primary tests should be possible at this level, sparing the hospitals the workload of outpatient assessment. This change in patient flow requires a lot of training and expansion of the current capacity of some outpatient facilities, which will be richly repaid in the additional hospital capacity it opens up to patients who really need it. There should also be a free flow of information between primary and higher levels of care, both for children with COVID-19 and for others, to rule out complications arising after the acute period. Daily telemedicine follow-up with proper explanations to help the family deal with the sick child is prioritized in this strategy.
The authors sum up: “It is necessary that physicians, institutions, policymakers, and families all together prepare themselves on time to face in the best way the difficulties of the near future; otherwise, we will find ourselves facing the same problems experienced during the first wave of SARS–CoV-2.”