Pediatric Emergency Medicine: Learning from Each Other

Early in the COVID-19 epidemic, the Pediatric Emergency Medicine North American Chiefs (PEMNAC) used our email list to ask questions, provide information and discuss key medical and operational issues with about 140 pediatric emergency medicine (PEM) chiefs across the U.S. and Canada. We learned from firsthand experiences, including those who were affected early or especially hard.

As it became clear that children were not the primary coronavirus target, we discussed other ways we could help, which included refocusing or shutting down pediatric emergency departments (EDs) and caring for older populations in areas of need.

When the Pediatric Academic Societies meeting was canceled, we held a virtual PEMNAC meeting focused mostly on COVID-19. Our meeting included colleagues from Italy, who had been affected by COVID in ways that many of us had not, as well as U.S. ED and infectious disease experts. Through presentations and discussion, we learned an amazing amount about the virus, its trajectory, our successes and failures, and the evolving concern for the Kawasaki-like syndrome reported in Europe and New York City.

The group surveys our members frequently, which provides invaluable data on staffing models, costs and ways to ensure that PEM remains a viable safety net for individual facilities, systems and regions. It was clear that our disaster and infectious disease preparations and the resilience of emergency systems/providers, including physicians, nurses, ancillary team members and prehospital providers, would enable us to care for patients and families in a way that would optimally protect our providers. We used this up-to-date national information and data to inform our leaders and help design new and innovative ways to manage patients, families, personal protective equipment and processes.

We've also learned from each other to recognize and address stress, burnout, anxiety and fear in ourselves and our colleagues.

— George A. Woodward, M.D., M.B.A., FAAP, chair of the Pediatric Emergency Medicine North American Chiefs

Pediatric Palliative Care: Finding Hope in the Face of Uncertainty

As the COVID-19 pandemic hit, pediatric palliative care (PPC) teams mobilized in a number of truly innovative ways.

The PPC team at Children’s Hospital at Montefiore in Bronx, N.Y., developed an incredible surge-in-place program, quickly training colleagues from other fields to provide palliative and bereavement care to adults in their larger hospital community (https://bit.ly/3k0yBwc, https://bit.ly/3hVoVRQ).

Colleagues in adult palliative care developed the COVID Vital Talk Playbook (https://www.vitaltalk.org/guides/covid-19-communication-skills/) for communication with adults and their families. Shortly thereafter, PPC colleagues released a version adapted for pediatrics. Teams offered their services at neighboring adult hospitals, obtaining emergency privileges and helping them to flex up their palliative care workforce at a time when so many adults are dying of this terrible disease.

Pediatric palliative care subspecialists also helped develop symptom management protocols in the event of ventilator shortages, pivoted to virtual bereavement support groups for grieving families, informed family presence policies and learned new ways to work as an interdisciplinary team while staying safely physically distanced.

As our colleague, Chris Adrian, M.D., wrote so beautifully, “…working with families over months and years teaches you to hope that life reconstitutes on the other side of catastrophe, and that people can find joy in living again on the far side of unbearable loss” (https://bit.ly/2DsGKbR). And so, despite it all, we found hope.

As we all cope with the uncertainty introduced by the COVID-19 pandemic, the experience gives us a glimpse into one aspect of the lives of our patients with serious illness and their families. Many have lived with deep uncertainty before the pandemic and will continue to live with it after the pandemic is gone.

We continue to support patients with serious illness and their families and hope that in the coming months, our services are needed less and less.

— Elissa Miller, M.D., FAAP member of the AAP Section on Hospice and Palliative Medicine

Developmental and behavioral pediatrics: Returning to our roots

Developmental-behavioral pediatricians (DBPs) thought, “we have to see our patients in person!” Then overnight, we went remote. We adapted and found we’re well-suited to operate in the setting of a pandemic. We’ve shifted much of our practice to supporting families facing uncertainty.

Managing ambiguity is the superpower of DBPs. We’re accustomed to developmental changes, varied symptoms across settings and evolving diagnostic categories.

To diagnose autism, we assess facial expression during play and conversation. Since we can’t play with very young children mask-free, we now rely more on history and observation. None of the remote or “no-touch” diagnostic testing options are yet validated, but the bar isn’t lowered; the priority is to do no harm. Delaying a diagnosis when treatment is most effective would confer harm.

For children and teens with attention-deficit/hyperactivity disorder, we now focus on at-home behaviors. Many parents observe how hard learning is or how short their child’s attention span is. We use digital measures to diagnose learning and cognitive disorders, typically tools already validated for remote use (https://iopc.squarespace.com/teleneuropsychology-research). Recommendations now include supporting students during remote education.

We’ve shifted how we think about mental health disorders. During social isolation, anxiety, depression and sleep disruption may be medication side effects, co-morbid disorders and/or results of pandemic-related upheavals. Children are at increased risk for abuse; family stress is high. We’ve returned to our professional roots, thinking about each child’s strengths, weaknesses and function within an eco-bio-developmental context. The psychosocial stressors of their ecology have become a focus: How can we support a child and family in this moment in history?

Telehealth is a new window into family life. We see more family dynamics and watch children function in the most comfortable setting. As a field, we must develop new ways to diagnose/monitor accurately, without the regularity of school and office materials, but (payment allowing) I suspect telehealth will be a long-lasting part of DBP care.

— Alison D. Schonwald, M.D., FAAP, member of the AAP Section on Developmental and Behavioral Pediatrics