Preparing Adult Clinicians to Treat Pediatric Patients

The first week of December marked the 17th consecutive week with more than 100,000 COVID-19 cases among children in the United States.¹ On December 2, children made up more than 22% of positive cases. Since the onset of the pandemic in March 2020, more than 7 million children in the United States have tested positive for COVID-19.¹
 
With the rise in cases among children across the country, more healthcare professionals who typically work with adult patients are being tasked with treating pediatric patients. To help smooth this transition, the Society of Critical Care Medicine hosted two webcasts titled “Preparing Adult Clinicians to Treat Pediatric Patients.”
   
The webcast panel comprised these subject matter experts:
 

• Edward E. Conway Jr, MD, MS, FAAP, FCCM, chief of pediatric critical care medicine, vice chairman of the Lewis M. Fraad Department of Pediatrics, and professor at Albert Einstein College of Medicine in Bronx, New York, USA
• Sonny Dhanani, MD, pediatric intensive care unit chief at Children’s Hospital of Eastern Ontario in Ottawa, Ontario, Canada
• Elizabeth A. Farrington, BCNSP, BCPS, PharmD, clinical associate professor at New Hanover Regional Medical Center in Wilmington, North Carolina, USA
• Elaine Gilfoyle, BSc (Hons.), MD, MMEd, FRCPC, division head and pediatric intensive care unit medical director at the Hospital for Sick Children in Toronto, Ontario, USA
• Maureen A. Madden, DNP, RN, CCRN, CPNP, FCCM, acute care pediatric nurse practitioner at Bristol Myers Squibb Children’s Hospital and professor at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey, USA
• Michelle M. Ramirez, MD, FAAP, pediatric intensivist at Hassenfeld Children’s Hospital at New York University and Langone Medical Center in New York, New York, USA

 
Both webcasts were moderated by Randy S. Wax, MD, MEd, FCCM, associate professor in the Department of Critical Care Medicine at Queen’s University/Lakeridge Health in Oshawa, Ontario, Canada.
 
In the webcasts, these healthcare professionals brought to light a number of key themes they observed during their time treating children with COVID-19, many of which continue to be relevant for all clinicians. 

Delineation Between Children and Adults

 Children’s and adults’ bodies have obvious major differences but the provision of medical care sometimes blurs these differences. Historically, the pediatric intensive care unit (PICU) was intended for patients from birth to age 18 years. The pandemic, however, has required that some pediatric patients be relocated to the adult intensive care unit (ICU).
 
“From a physiologic basis, what patients in crisis might we consider to be suitable for management in a center outside the pediatric realm?” asked Dr. Dhanani. “That’s variable, but physiology after about 12, and puberty for sure, so maybe 15 or 16, tends to fall into the wheelhouse of a more adult-type patient. The cardiovascular system is developed, the respiratory system, and types of illness often follow a more adult trajectory as far as how they’re managed.”
 
Several panelists discussed the idea of using weight as a standard tool to define whether a patient should be treated as a child or an adult. The problem with this approach is the prevalence of obesity across the country, particularly among children. The Centers for Disease Control and Prevention (CDC) reports that one in five children has obesity.² Because of this, a patient’s weight might not accurately indicate their physical and developmental age.
 
Dr. Conway said that the most common comorbidity he saw among pediatric COVID-19 patients at his facility was obesity. Patients with obesity are more likely to have serious COVID-19 illness—this includes pediatric patients. A study of children who tested positive for COVID-19 found that the risk of hospitalization was three times as high for obese children as for nonobese children. The risk of severe illness, including ICU admission, invasive mechanical ventilation, and death, of hospitalized children with COVID-19 was 1.4 times as high for obese children than for nonobese children.³

Multisystem Inflammatory Syndrome in Children

The CDC describes multisystem inflammatory syndrome in children (MIS-C) as “a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.”⁴ The cause of MIS-C is unknown, but many children who are diagnosed with it previously had COVID-19.⁴
 
Dr. Dhanani explained that MIS-C presents similarly to several other pediatric illnesses, including Kawasaki disease. A clinician who believes a patient may have MIS-C should turn to colleagues who specialize in the inflamed body part for guidance and assistance. “Pediatricians and pediatric intensivists are used to looking for multisystem inflammatory diseases and getting consultations from rheumatologists and cardiologists and immunologists together to comanage it, and that would be my recommendation,” Dr. Dhanani said. “If you see something similar to this, bring the experts together to manage it. The approach is multifactorial.”

Similarities and Differences of Care Methods

COVID-19 can cause respiratory problems in patients of all ages, and Dr. Dhanani reminded viewers that pediatricians and other clinicians who treat children are used to seeing surges in respiratory illnesses at this time every year. “It’s our bread and butter,” he said. “This is what we do every November to March. Most pediatric hospitals have built systems for those types of surges.”
 
Several panelists spoke about high-flow nasal cannula for pediatric patients with COVID-19, despite the concern, particularly early in the pandemic, about aerosol dispersal and its potential for clinician infection. Propofol is used as frequently in children as in adults. Extracorporeal membrane oxygenation is a potential treatment for children severely impacted by COVID-19. Several panelists said that perhaps the most similar aspect between pediatric and adult patient care is the use of proning. “We’ve got some experience with respiratory viral illnesses,” Dr. Dhanani said. “I don’t think the strategies are different from what has been used extensively in adult ICUs to manage COVID-19.”

Opportunities for Parent Support

Some of the most heartrending stories early in the pandemic were about patients who died from COVID-19 without having any family members by their side. Other than medical team members, these patients died alone. Dr. Madden explained that Bristol Myers Squibb Children’s Hospital made sure that parents are still permitted to visit children with COVID-19 and not just visit but actively participate in the decision-making process related to the care of their children.
 
“That may be something that is a discreet difference that needs to be considered if pediatric patients are moving over to the adult realm where there may be visitor limitations in place,” she said. “There may need to be some modifications made for that, in particular if they have underlying disorders or are developmentally delayed. So age and weight are not the sole characteristics.”

Pediatric Fundamental Critical Care Support Course

Clinicians who want to strengthen their expertise or refresh their knowledge about pediatric patients can take SCCM’s Pediatric Fundamental Critical Care Support (PFCCS) course, which several panelists recommended. The course prepares nonintensivists to recognize critical illness and initiate care for the critically ill pediatric patient. It is recommended for any healthcare professional who may encounter a critically ill or injured pediatric patient.
 
Dr. Ramirez said that the fellows, residents, nurse practitioners, and respiratory therapists at her institution have attended a PFCCS course. “It gives the fundamentals and basics of pediatric critical care,” Dr. Ramirez said. “It has initial ventilator strategies for pediatric patients, intubation, management of shock—all the bread-and-butter critical care topics. That would be a great resource for anyone looking to getting some foundational work on pediatric patients.”
 
This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention (grant number 1 NU50CK000566-01-00). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). Its contents do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.
 
References

1. American Academy of Pediatrics. Children and COVID-19: state-level data report. Last updated December 6, 2021. Accessed December 10, 2021.  https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report.
2. Centers for Disease Control and Prevention. Childhood obesity facts. Prevalence of childhood obesity in the United States. Page last reviewed April 5, 2021. Accessed December 10, 2021. https://www.cdc.gov/obesity/data/childhood.html
3. Kompaniyets L, Agathis NT, Nelson JM, et al. Underlying medical conditions associated with severe COVID-19 illness among children. JAMA Netw Open. 2021 Jun 1;4(6):e2111182.
4. Centers for Disease Control and Prevention. For parents: multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Page last reviewed September 20, 2021. Accessed December 10, 2021. https://www.cdc.gov/mis/mis-c.html.