Caring for Critically Ill Children With Coronavirus Disease 2019: Uncharted Territory and Fuzzy Maps*

Courage is the human virtue that counts most—courage to act on limited knowledge and insufficient evidence that’s all any of us have —Robert Frost Coronavirus disease 2019 (COVID-19) has posed unprecedented challenges globally and has exposed the underbelly of poorly resilient systems and lack of coherent public health government policies worldwide. Much has been written about the ravages of COVID-19 on economies globally and the disruption of the social fabric of society. COVID-19 has also posed a logistical nightmare to policy makers, families, and governments across the world as a result of the surge in laboratory proven cases as well as overwhelmed healthcare systems and high mortality rates. The unprecedented spread and virulence have led to policies aimed at maintenance of essential services while decreasing nonessential services, which has resulted in the sharp downturn in economies worldwide. These policies have also resulted in an increase in health disparities whereby marginalized and vulnerable populations have borne a disproportionate burden of COVID-19-proven infections and death and disabilities (1). Although we are inundated with reports seemingly on an hourly basis about the burdens imposed by COVID-19 on healthcare services and medical teams and the loss of lives, those caring for the critically ill patients are handicapped by many unknowns. That over 48,000 articles (over 3,000 in children) have been indexed in PubMed since January 2020 with no randomized trials in children speaks to the enormity of the task of separating the wheat from the chaff (2). What has plagued our pediatric critical care colleagues worldwide is little knowledge of the pathophysiology, and even less about treatment and hence how to provide care for children with severe COVID-19 infections. Armed with a voluminous and rapid rate of publications yet little concrete advances in children to craft recommendations, some experts have relied on pertinent adult literature (3). Clinicians providing care for children with COVID-19 faced with a little or no experience and the inability to sift through the literature welcome guidance and recommendations even though informed mostly by expert opinion and adult experience. It is in this evershifting information landscape that the European Society of Paediatric Neonatal Intensive Care (ESPNIC) Scientific Sections Collaborative drafted useful and pragmatic practice recommendations for the management of critically ill children with COVID-19 (4). Their recommendations are based on scant literature and opinions based on decades of experience in caring for critically ill children. These recommendations serve as a useful quick reference for critical care practitioners, which succinctly summarizes the salient differences in approach to critically ill children with COVID-19 and provides references for other aspects of contemporary critical care, which are relevant to COVID-19 children. Their recommendations are relevant to caring for children in intensive and intermediate care units and are based on a literature review of studies from the start of the pandemic to July 10, 2020 (4). These recommendations also build on previous ESPNIC statements or consensus articles on a variety of topics that are relevant to both general care of critically ill children as well COVID-19 (5). The authors offer an insightful and nuanced approach for the provision of respiratory support for children with COVID-19. This is a hotly debated topic among both adult and pediatric critical-care practitioners. Much is unknown about why children suffer from similar symptoms yet milder disease than adults (6). Several postulates have been offered, yet these fail to explain fully this phenomenon that runs counter to critical illness due to most other respiratory pathogens (7,8). This lack of understanding confounds preparation for provision of pediatric critical care services (9). A major dilemma is whether respiratory deterioration, including pediatric adult respiratory distress syndrome, is a common feature of critical illness in children; however, whether the acute respiratory distress syndrome phenotypes in adults with COVID-19 proposed by Gattinoni et al (10,11) exist in children is unknown. Shouldered with this uncertainty, the ESPNIC group relied heavily on previous expert opinions and recommendations in which many from this team participated (12,13). The need to protect teams especially during aerosol-generating procedures is a useful reminder in view of the increased risk to healthcare personnel (14,15). Intubation decisions (early versus delayed and the method used) and the increased risk of airborne transmission posed by COVID-19 are important considerations and adhere to the Pediatric Acute Lung Injury Consensus Conference as well as others (16). However, the possible role of microvascular thrombosis leading to unresolved hypoxemia and which may be worsened by mechanical ventilation is not a major consideration in everyday pediatric critical care practice. That clotting may also plague extracorporeal membrane oxygenation and renal replacement therapy circuits in children with COVID-19 are also not a feature of everyday pediatric critical care practice, and hence, the authors’ reminder of this issue and the likely need for anticoagulation are timely (4). Another issue faced by the pediatric critical care community is whether the recently described pediatric multisystem inflammatory syndrome—temporally associated with COVID-19, now called “multisystem inflammatory syndrome COVID” (MIS-C), is a postinfectious immune aberrant reaction (17) that mimics Kawasaki disease and therefore warrants long-term follow-up because of concerns about the development and progression of coronary aneurysm. Children with severe COVID-19 disease with or without MIS-C may present in shock due to fluid losses as a result of diarrhea, vomiting, and decreased intake but more commonly with shock related to cardiovascular compromise. The authors propose the use of the 2020 Pediatric Septic Shock Guidelines (18,19) with a few caveats. Apart from antibiotic administration (until bacterial sepsis is ruled out), the authors propose using IV immunoglobulin, steroids, and monoclonal antibodies if MIS-C results in shock, but in view of scant data, these therapies are best coordinated with subspecialty colleagues and/or in the context of a clinical trial. The unique issue pertaining to transport of children with possible COVID-19 infections, nursing considerations regarding organization of schedules, workload, and staff protection, as well as the enhanced role of spiritual and emotional care in order to provide psychologic support to families when visits are restricted as well as during bereavement are thoughtfully addressed. Other important contributions of the ESPNIC document are reminders of the ethical considerations of postponing scheduled surgeries, the consequences of social isolation and reduced staff presence to support children, and the deleterious effect of personal protective equipment especially on younger children. These are uncertain times and colleagues across the world have expended considerable time and energy preparing for the worst case scenario in COVID-19. Our interaction at conferences and other face-to-face fora to share experiences and support each other have been disrupted, and hence, our present reliance on online communications and written practice recommendations has assumed greater importance. Treatment of critically ill children affected by COVID-19 is fraught with uncertainty. Hence, reporting our experience and providing some recommendations provide clinicians with a road map albeit fuzzy with many forks in the road. The ESPNIC practice recommendations are sound as of July 2020 but subject to change as the tsunami of data and evidence leads to improved knowledge of pathophysiology and clinical manifestation of COVID-19.

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