Identification of children at high-risk for MIS-C


Every pediatric provider including pediatric nurse practitioners and pediatric nurses working in hospital or in outpatient settings must know the various ways children and adolescents may present with possible COVID-19 symptoms. They must also know which patients are at high risk of developing multisystem inflammatory syndrome in children (MIS-C).

In the July 2020 issue of Contemporary Pediatrics, in the clinical feature article “Multisystem inflammatory syndrome (MIS-C) in children associated with COVID-19,” Drs Schulman and Krilov present a comprehensive review of MIS-C, including the recognition of symptoms and current treatment. They compared the MIS-C presentation to Kawasaki disease (KD). Today, every pediatric provider including pediatric nurse practitioners and pediatric nurses working in hospital or in outpatient settings must know the various ways children and adolescents may present with possible COVID-19 symptoms. Pediatric nurse practitioners must also identify those children or adolescents in their practices that are considered high risk for MIS-C. Drs Schulman and Krilov identify high risk children as those who present with a fever and severe abdominal pain, whose median age is between 10 and 11 years (age range 4 to 21 years) as well as children with African heritage.

Contact tracing essential for early identification of high risk and asymptomatic children

States that have implemented COVID-19 contact tracing strategies to identify individuals and families with a possible or known exposure to COVID-19, are recommended to include questions about children and adolescents living in the home, including their ages. Gathering the information is important but most important is relaying this information to their pediatric providers who care for the children. Best practice may be for contact tracers to ask the parents or caregivers the names and contact information of their pediatric providers and ask the parents to inform their providers of the possible or known exposure to COVID-19. For those parents without access to a pediatric provider, it is advisable for contact tracers to provide names of community-based pediatric providers who will see the child or adolescent if problems should arise. Follow up by the contact tracers to assure the children or adolescents have informed their pediatric providers is essential.

Frequent monitoring of the children and adolescents via telehealth visits should be considered as part of their pediatric provider plan of care. Because symptom presentation and management of children and adolescents differs from adults, documentation of telehealth visits may provide some insights for possible unrecognized early symptoms in children or adolescents, thus better informing early symptom recognition and decision making for treatment management if and when they begin to display symptoms of COVID-19 or MIS-C.

In addition, it is believed that some children and adolescents may be asymptomatic carriers of COVID-19. Thus, if contact tracers are testing the children and adolescents with known exposures, pediatric providers and researchers will have data about asymptomatic children and adolescents that can be analyzed to better inform pediatric providers about the COVID-19 and MIS-C in children and adolescents as we are immersed in this pandemic.

Can experiences in the immediate past predict a safer future?

Although everyone is grateful that, overall, children have had less hospitalizations for COVID-19, in the heart of a pediatric provider, even one child who suffers with severe symptoms is one too many. In the United States, children with MIS-C symptoms were first identified in New York as physicians, nurses, and first responders were making every effort to fight the virus raging among the adult population. As Drs. Schulman and Krilov discussed, the children were most likely asymptomatic for 4 or more weeks before the presentation of symptoms.

Today, as COVID-19 surges are occurring in many southern states and the west coast of the United States, will more children and adolescents be presenting with MIS-C in mid to late August in those states? The critical question is: Can this be prevented or at least recognized early and treated? Strategies to protect all children and in particular, those who are considered at highest risk, should be implemented.

Pediatric providers in the states with current surges may want to reach out to advise parents to:

1.) Keep their children and adolescents at home or send the children to a relative’s home who has not had an exposure;

2). Keep the person(s) who were exposed separated from the children;

3). Wear masks if they must go out of the home; and

4). Adhere to all of the Center for Disease Control guidance for social distancing, child and adolescent play activities and hand hygiene.

We can set a goal for a better immediate future by talking with parents and their children/adolescents by encouraging them to implement these safety precautions. We do not know if these strategies will be effective. However, parents, children, adolescents, and pediatric providers need to work together to successfully maintain the health of children and adolescents throughout this pandemic and these simple strategies may inform a safer future.

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Tina Tan, MD, FAAP, FIDSA, FPIDS, editor in chief, Contemporary Pediatrics, professor of pediatrics, Feinberg School of Medicine, Northwestern University, pediatric infectious diseases attending, Ann & Robert H. Lurie Children's Hospital of Chicago
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