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Safe and Sound
Pediatric Tips for Keeping Kids and Families Healthy During COVID-19(and Beyond)
Heather Forkey, MD
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Overview
• What do we know about COVID-19, and COVID-19 and kids?• What are health issues to think about now?• What are ways to be ready for addressing health when Covid
closures are over?• What are some health issues to be aware of for kids in foster care
now and later, and how can you work with the doctor for best outcomes?
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Lots of conflicting information these days
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What is COVID 19- Corona virus disease of 2019
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Why is COVID worse than the flu:
• R0 number: Estimate of how many people will be infected by an average individual with the disease
• Incubation period: Time between exposure to having disease (can spread without knowing it)
• Hospitalization rate: How many people who get the disease will need hospital level support
• Case fatality rate: Percentage of reported deaths out of reported cases
Influenza vs. COVID-19
1.3 2- 2.4
1-4 days 1-14 days
5-19%
0.1% 1-3.4 %
2%
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Children and COVID 19 -symptoms
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Symptoms in just added
These symptoms may appear 2-14 days after exposure to the virus:
•Fever•Cough•Shortness of breath or difficulty breathing•Chills•Repeated shaking with chills•Muscle pain•Headache•Sore throat•New loss of taste or smell
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Children have no symptoms or very mild illness…Most often
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Paper out this week:Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review
• This systematic review of pediatric cases of COVID-19 shows that most children and adolescents who were infected by SARS-CoV-2 (ie, tested positive by nasopharyngeal swab) presented with mild symptoms.29-31 Frequent clinical manifestations included fever, dry cough, and fatigue accompanied by other upper respiratory symptoms, such as nasal congestion and runny nose.31 Moreover, the main gastrointestinal symptoms were nausea, vomiting, and diarrhea, which were reported in a few cases, particularly in a newborn and infants.
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What if you need to go to the doctor or hospital
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Testing for Covid
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Antigen testing vs. antibody testing
Testing for the disease
Testing for immunity to the disease
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Antigen testing
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Antibody testing
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Immunity -Have you herd?
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What have you herd?
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How do we get immune (get antibodies)
• Get the disease – too dangerous• Get the vaccine – not ready yet• Not sure the disease or vaccine will
work to provide immunity?
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Masks??
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Face masksCloth face coverings should—
• fit snugly but comfortably against the side of the face • be secured with ties or ear loops • include multiple layers of fabric • allow for breathing without restriction • be able to be laundered and machine dried without damage or change to shape
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Masks on kids?
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What about kids who have some symptoms that overlap with COVID
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Additional things that can help
• Separate as much as you can in the house • Avoid sharing personal household items – dishes, eating utensils,
towels, bedding• Clean all high touch surfaces with household cleaner at least once per
day– counters, tabletops, doorknobs, phones, bathroom fixtures
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What about kids that leave home (or a program) and then come back?
• Concerns• Usual concerns• New ones with COVID-19
• Symptoms?
• Testing?
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How can we do medical visits
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Who should continue to get health care now
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Why do we worry more about the health of kids in foster care
• Up to 60-92% at least 1 chronic health problem• 25-40% 3 or more chronic health problems• 25-33% fail vision or hearing screens• 40% low birth weight or premature• Obesity rates up to twice as high as matched peers• 30-60% developmental disability• Up to 85% prevalence of mental health disorders
Szilagyi MA, Rosen DS, Rubin D, Zlotnik S, Council on Foster Care Adoption and Kinship Care, Committee on Adolescence, Council on Early Childhood. Technical Report: Health care issues for children and adolescents in foster care and kinship care. Pediatrics. 2015;136(4):e1142-66. doi: 10.1542/peds.2015-2656
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Chaiyachati BH, Wood JN, Mitra N, Chaiyachati KH. All-Cause Mortality Among Children in the US Foster Care System, 2003-2016. JAMA Pediatr. Published online April 20, 2020. doi:10.1001/jamapediatrics.2020.0715
Children in foster care are 42% more likely to die than children in the general population
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Coordination with bio family, foster family, medical, mental health, early intervention, school, court
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Follow up visits more frequent schedule
• 0- 6 months: Monthly
• 6mo to 2 years: Every 3 months• Over 2: Twice per year
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Information management – how to get information about your child and how to get it to people who should have it
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Information exchange: Medical memory
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Information inContact at child welfare office, or protocol to have referrals made
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Information: What foster families need
• Foster parents frustrated by • Lack of medical information on children in their care• Unique medical and behavioral health issues of children in foster care have• Having to get info themselves• Need support with health needs – fighting for things that should be
automatic, safety of children with health needs a concern
• (Greiner, Ross et al. 2015)
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Information – What is required
• Releases – consents• State and county rules about who to share info with, what need to get info
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Information – issues of confidentiality• Confidentiality concerns
• Parent's health history is confidential (parent can share it him/herself)
• Child’s medical history is not restricted: child welfare, foster parent or medical provider - all providers of care and thus need to have information to provide care
• HIPPA rules impact who can share information with you, what documentation you need to get it
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Recommended to be seen before 7 days post placement for screening
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Getting access - scheduling
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Medical Evaluations: Francine Cournos experience
“The morning of my placement into foster care I first went to (the headquarters of the foster care agency) to have a physical examination, and, I imagined, do whatever else must be done to transform me into a foster child. I had trouble believing it was happening. I was a horse and they were checking my hooves and teeth. I saw myself being sold into slavery. Before I could go to the foster home, they had to examine me for defects and diseases. I wondered what they would do if they found any.”
Cournos, F. (2006) City of One.
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Health Evaluations: Initial evaluation
• Vitals: height, weight, blood pressure in older kids• Signs of injury, neglect• Active medical/psychiatric problems: illness, injury, disability• Developmental and MH screening• Medications• Allergies to foods, med, environment• Upcoming medical appts• Need for eyeglasses, hearing aids, or other medical equipment• Infant: delivery hx (where, when, how, tox screen, complications)
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Height, weight, blood pressure
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Growth concerns
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Urgent things to identify
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Steele JS, Buchi KF. Medical and Mental Health of Children Entering the Utah Foster Care System. Pediatrics. 2008;122(3):e703-e709.25.Halfon N, Mendonca A, Berkowitz G. Health status of children in foster care. The experience of the Center for the Vulnerable Child. Archives of Pediatrics & Adolescent Medicine. Apr 1995;149(4):386-392.
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Dental concerns
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Evaluations: Substance exposure
• Substance exposure• Fetal Alcohol Syndrome/ Alcohol
Related Neurodevelopmental Disorder
• Cocaine exposure• Opiate exposure• Methamphetamine exposure
• Newborn screen info
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Medications: Review prescriptions, what to give and when
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Durable Medical Equipment
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Initial evaluations provide first information to identify medical resource
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Health Evaluations: Comprehensive Evaluation within 30-45 days of placement
Medical
Developmental/academic
Dental
Substance abuse
Mental health
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Physicals need to be complete
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Concerns• Takayama JI, Wolfe E, Coulter KP. Relationship between reason for placement and medical findings among children in foster care. Pediatrics. Feb 1998;101(2):201-207.
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Developmental Evaluation
Jee SH, Conn KM, Nilsen WJ, Szilagyi MA, Forbes-Jones E, Halterman JS. Learning difficulties among children separated from a parent. Ambulatory Pediatrics. May-Jun 2008;8(3):163-168.
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Evaluations: Substance abuse
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Evaluations: Laboratory studies needed• Routine
• CBC – Anemia concerns
• Tuberculosis testing if needed
• Lead for kids under age 6 or if delays that lead to hands in mouth
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Laboratory issues
• To consider if risk factors present: Vertical transmission or exposure thru sexual abuse
• HIV: • Hepatitis B, C• Syphilis• Urine testing – GC, chlamydia, trichomonas
• Appropriate to risk• Pregnancy• Lipids• Diabetes testing - Hemoglobin A1C
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Immunizations
• Tdap • HPV • Meningococcal• Influenza• Chicken pox• Rotavirus• Pneumococcal• Hepatitis A• …..covid 19???
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Risk factors for early initiation of sexual activity
Ahrens KM et al., Laboratory-diagnosed sexually transmitted infections in former foster youth compared with peers, Pediatrics, 2010, 126(1):97–103
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Child welfare usually not have policies to address these issues with teens in care
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Relationships with bio family, missing siblings, lack of involvement in normalizing activities are issues
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Attention to visits with parents
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Reassuring, Restoring Routine, Regulating
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Reassurance – restoring safety
Danger
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Restoring safety
• Relaxation techniques
• Use 5 senses
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Restoring safety
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Routines communicate safety, shutting down stress response
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Routines of positive interactions: predictable compassionate availability
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Regulation
• Trauma limits self regulation, ability to describe feelings or internal states, and ability to communicate wishes and desires
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Anger example
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Sesame street resources
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Identify resources in your community
• Trauma focused therapies best supported by evidence• Young children
• Child Parent Psychotherapy (CPP): 0-6 years• Parent Child Interaction Therapy (PCIT): 2-12 years
• Children and Adolescents (3-18 yo)• Trauma Focused – Cognitive Behavioral Therapy (TF-CBT)
• Complex trauma• Attachment, Self Regulation and Competency (ARC)• Integrative Treatment of Complex Trauma for Children and Adolescents (ITCT-C, ITCT-A)