COVID-19 Pediatrics Round Up

  • Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr.Published online March 26, 2020. doi:10.1001/jamapediatrics.2020.0878
    • Thirty-three neonates born to mothers with COVID-19, including 3 neonates with COVID-19, were identified
    • clinical symptoms from 33 neonates with or at risk of COVID-19 were mild and outcomes were favorable.
    • 3 of 33 infants (9%) presented with early-onset SARS-CoV-2 infection.
    • vertical maternal-fetal transmission cannot be ruled out
  • Zeng H, Xu C, Fan J, et al. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. Published online March 26, 2020. doi:10.1001/jama.2020.4861
    • Retrospective review of 6 pregnant women with COVID-19 admitted to Zhongnan Hospital of Wuhan University from February 16 to March 6, 2020, confirmed based on symptoms, chest computed tomography, and positive RT-PCR results.
    • All 6 mothers had mild clinical manifestations. All had cesarean deliveries in their third trimester in negative pressure isolation rooms. All mothers wore masks, and all medical staff wore protective suits and double masks. The infants were isolated from their mothers immediately after delivery.
    • All 6 infants had 1-minute Apgar scores of 8 to 9 and 5-minute Apgar scores of 9 to 10. Neonatal throat swabs and blood samples all had negative RT-PCR test results.
    • All 6 infants had antibodies detected in their serum. Two infants had IgG and IgM concentrations higher than the normal level (<10 AU/mL)
    • Inflammatory cytokine IL-6 was significantly increased in all infants.
  • Kimberlin DW, Stagno S. Can SARS-CoV-2 Infection Be Acquired In Utero? More Definitive Evidence Is Needed. Published online March 26, 2020. doi:10.1001/jama.2020.4868: COMMENT ON PREVIOUS PUBLICATION
    • Evidence for such transmission is based on elevated IgM antibody values in blood drawn from the neonates following birth. All infants also had elevated IgG antibody values and cytokine levels, although these may have crossed the placenta from the mother to the infant. No infant specimen had a positive reverse transcriptase–polymerase chain reaction test result, so there is not virologic evidence for congenital infection in these cases to support the serologic suggestion of in utero transmission. These data are not conclusive and do not prove in utero transmission.
  • Guidance on breast feeding from CDC

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html

Guidance on breastfeeding for mothers with confirmed COVID-19 or under investigation for COVID-19

Breast milk is the best source of nutrition for most infants. However, much is unknown about COVID-19. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and healthcare providers.  A mother with confirmed COVID-19 or who is a symptomatic PUI should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while feeding at the breast.  If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant.

 

Mental Health Issues in COVID-19

 

  • Lai J et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open2020 Mar 23; 3:e203976. (https://doi.org/10.1001/jamanetworkopen.2020.3976)
    • Cross-sectional, geographically stratified survey of 1257 healthcare workers (39% physicians; 61% nurses; 72% of nurses had junior titles) from 34 hospitals (20 in Wuhan; 7 elsewhere inside Hubei province, and 7 outside the province).
    • The researchers used validated rating scales to assess anxiety, depression, insomnia, and distress/post-traumatic stress symptoms from January 29 to February 3, 2020, close to the Wuhan outbreak’s peak.
    • 42% were directly caring for patients with COVID-19
    • There were high rates of depression (50%), anxiety (45%), insomnia (34%), and distress (72%); median scores, however, barely reached the mild range.
    • Symptoms were higher in nurses, women, people caring for COVID-19 patients, and those in Wuhan (symptoms were lowest outside Hubei). Of these higher-risk groups, 10% to 20% scored in the moderate or severe range.
  • https://www.thelancet.com/action/showPdf?pii=S2352-4642%2820%2930096-1

Mental Health of children placed under quarantine for COVID-19

 

Advocacy

https://www.nejm.org/doi/10.1056/NEJMp2005953

Undocumented U.S. Immigrants and Covid-19 Kathleen R. Page, M.D., Maya Venkataramani, M.D., Chris Beyrer, M.D., M.P.H., Sarah Polk, M.D., M.H.S.

 

  • aliens are inadmissible to the United States if they are unable to care for themselves without becoming public charges” (uscis.gov/greencard/public-charge.) wef Feb24th, 2020
  • March 24,2020: USCIS encourages all those, including aliens, with symptoms that resemble Coronavirus Disease 2019 (Covid-19) (fever, cough, shortness of breath) to seek necessary medical treatment or preventive services. Such treatment or preventive services will not negatively affect any alien as part of a future Public Charge analysis
  • The Affordable Care Act excludes undocumented immigrants from eligibility for coverage, and an estimated 7.1 million undocumented immigrants lack health insurance, and routinely use the ED for healthcare. Telling people now to avoid EDs and call their doctors leaves those without PCPs in limbo.
  • Although the immigrant community tends to be young and healthy, the prevalence of diabetes, a risk factor for severe Covid-19, is 22% among Latinos, the highest for any U.S. racial or ethnic group
  • Even among those with a PCP, the rapid transition to telemedicine will be difficult for patients with limited English proficiency who may lack access to computers for videoconferencing and have to rely on telephonic visits involving interpreters, without the benefit of visual cues.
  • Many immigrants will have no income and are excluded from the social safety net. The $1 trillion economic relief package, which includes paid-leave benefits and direct cash for Americans, will not reach most undocumented immigrants or their families.
  • children of immigrants who disenrolled in SNAP will not receive school lunch services.

Article suggests following steps

  • The Families First Coronavirus Response Act (FFCRA) passed on March 18 provides coverage for Covid-19 testing for the uninsured through National Disaster Medical System reimbursements. This is welcome news but does not go far enough.  All care associated with patients with symptoms of Covid-19 should be covered, regardless of insurance status.
  • Establishing multilingual Covid-19 hotlines through the 211 system with capability and clinical backup to triage calls from symptomatic people could help bridge the gap to care for those lacking a PCP.
  • low-flight-risk immigrants should be released from detention

Novel therapies Update:

22 studies worldwide actively recruiting<18 yrs ( clinicaltrials.gov)

  • https://www.nejm.org/doi/full/10.1056/NEJMoa2001282?query=featured_coronavirus#article_citing_articles
    • In hospitalized adult patients with severe Covid-19, no benefit was observed with lopinavir–ritonavir treatment beyond standard care.
  • An Australian multi-centre, randomised controlled clinical trial of the Bacille Calmette-Guerin (BCG) vaccine has been endorsed by the Director-General of the World Health Organization (WHO), Dr Tedros Adhanom Ghebreyesus. Netherlands also has a study- both being conducted on HCW.
    • Although originally developed against tuberculosis – and still given to over 130 million babies annually for that purpose – BCG also boosts humans’ ‘frontline’ immunity, training it to respond to germs with greater intensity. A number of studies have already shown individuals who receive the vaccine develop fewer viral respiratory tract infections than those who haven’t, and the researchers hope this improved ‘innate’ immunity will provide crucial time to develop and validate a vaccine specific to the new coronavirus.
  • Convalescent Plasma Trial started in NY,MN: by invitation only

Open study: Post-exposure Prophylaxis / Preemptive Therapy for SARS-Coronavirus-2 (COVID-19 PEP)

https://clinicaltrials.gov/ct2/show/NCT04308668?recrs=a&cond=Coronavirus&map_cntry=US&draw=2&rank=4

Study Objective:

  1. To test if post-exposure prophylaxis with hydroxychloroquine can prevent progression development of symptomatic COVID19 disease after known exposure to the SARS-CoV2 virus.
  2. To test if preemptive therapy with hydroxychloroquine can prevent progression of persons with known symptomatic COVID19 disease, preventing hospitalization.

Inclusion Criteria:

  • Provision of informed consent
  • Exposure to a COVID19 case within 4 days as either a healthcare worker or household contact, OR
  • Symptomatic COVID19 case with confirmed diagnosis within 4 days of symptom onset OR symptomatic healthcare worker with known COVID19 contact and within 4 days of symptom onset;

Exclusion Criteria:

  • Current hospitalization
  • Allergy to hydroxychloroquine
  • Retinal eye disease
  • Known glucose-6 phosphate dehydrogenase (G-6-PD) deficiency
  • Known chronic kidney disease, stage 4 or 5 or receiving dialysis
  • Weight < 40 kg
  • Known Porphyria
  • Current use of: hydroxychloroquine or cardiac medicines of: flecainide, Tambocor; amiodarone, Cordarone, Pacerone; digoxin or Digox, Digitek, Lanoxin; procainamide or Procan, Procanbid, propafenone, Rythmal)

Rational use of facemasks for covid-19

https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30134-X/fulltext

 

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