Clinical features and acute management in children

Children account for a minority of cases of SARS-CoV-2 infection. The majority with acute infection are asymptomatic or have mild disease. Severe disease and mortality are reported in children with associated comorbidities such as complex neurodisability. Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS;also referred to as multisystem inflammatory syndrome in children (MIS-C)) is observed ~3-6 weeks after acute infection in an estimated 0.05% of cases. This is characterised by multiorgan involvement, and >50% of cases have myocardial dysfunction and require critical care admission for supportive care. Neurological, cardiac, gastrointestinal, renal and dermatological symptoms are all reported in acute and post-acute SARS-CoV-2 infection. To date, there is no evidence of a benefit from remdesivir, steroids or other investigative treatment in children during acute infection, and their use is recommended only on a case-by-case compassionate basis. Management of PIMS-TS is based on evidence from Kawasaki disease with immunomodulation and cardiac protection, and urgent RCT data are required. The collateral effects of the pandemic are likely to have long-term effects on children's physical and mental health.Copyright © ERS 2021.

Impact of the Covid-19 Pandemic on the Epidemiology and Disease Severity in Children with Bronchiolitis Admitted to a Tertiary Paediatric Intensive Care Unit (Picu)

BACKGROUND AND AIM: Children in the United Kingdom (UK) had reduced exposure to respiratory viruses (except severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2)) owing to major public health restrictions in 2020 and early 2021. We aim to describe disease severity and causative viruses in children with bronchiolitis presenting to a single tertiary PICU following relaxation of public health restrictions in 2021. METHOD(S): Retrospective review of the local PICANet database data from 01/03/2019-29/02/2020 'baseline season' compared to 01/03/2020-28/02/2021 'restriction season' and 01/03/2021-31/10/2021 'opening season'. Included were all patients admitted to PICU diagnosed with bronchiolitis and below the age of two years. RESULT(S): Data from the 'restriction season' showed a clear absence of respiratory syncytial virus but was otherwise highly flawed by PICU closures and changed logistics and thus not further analysed. There were 91 admissions to PICU during the 'baseline season', and 71 in the 'opening season'. There was a significant increase in the proportion of children above 1 year of age with bronchiolitis requiring intensive care (p<0.05). Paediatric index of mortality 3 (PIM-3) score, length of PICU stay, duration of invasive mechanical ventilation and requirement for vasoactive medications were all lower in the 'opening' cohort. No children presented with SARS-CoV-2 bronchiolitis. Mixed infections were significantly less common in the 'opening season' (p<0.05). CONCLUSION(S): Children with bronchiolitis requiring paediatric intensive care management following easing of restrictions for the SARS-CoV-2 pandemic appear to be older and have reduced severity of illness compared to those in the season before. SARS-CoV-2 does not appear to cause severe bronchiolitis.

Setting up a Post Covid-19 Syndrome Service for Children and Young People across London - a Collaboration across Three Trusts

Aims Describe an interdisciplinary hub and spoke healthcare model for children and young people (CYP) with Post COVID-19 Syndrome Methods From November 2020, with NHS London and NHS England support, clinicians and AHP chief with backgrounds in infectious disease, adolescent medicine and psychiatry from across trusts in London collaborated to set up a hub and spoke model for delivering care to CYP with post COVID-19 syndrome. This was an iterative process with involvement of patient cohort. CYP are referred into a central weekly virtual multi-disciplinary 'hub' meeting for discussion with specialists across infectious disease;respiratory;rheumatology;neurology;chronic conditions (including ME/CFS );mental health;and allied health practitioners (AHP) with experience of rehabilitation including occupational therapists, and physiotherapists, dieticians, safeguarding practitioners. The groups has a diversity lead.The group has regular evidence-based CPD. Referrers (local paediatricians or GPs for 17-18 year olds) present patient to the MDT for discussion of diagnosis, investigation and management. Website-housed referral pathways including recommended baseline assessments are provided for referrers. A developing group of local integrated care service paediatric and AHP champions support local management, pathways and education around post COVID-19 syndrome. Patients follow one of two pathways: 1. Local management, using already available services which the MDT support 2. Face-to-face interdisciplinary consultation and rehabilitation for severe or complex cases. Local support MDT discussion, and advice to local team with letters to patients outlining impression and advice;school adjustments letters;leaflets for health professionals and CYP/ family across a range of known Post COVID symptoms and difficulties. AHP delivered virtual groups and webinars include pacing;emotional wellbeing;symptom management;eating, and sleep. As the first established post- COVID-19 service for CYP in England, we have led and supported the development of 14 other MDTs nationally. Results Between 1st April 2021 and 1st February 2022 89 patients were referred to the virtual MDT. All have received information leaflets to aid recovery. 25 CYP/families have attended the virtual groups so far. 57 CYP have received an interdisciplinary consultation and received bespoke MDT input. (see table 1) Conclusion In response to the clinical need of CYP with post COVID symptoms, the collaborative development of a Pan London service across 2 clinical sites, and 3 NHS trusts is an example of how specialist clinical care can be delivered virtually using a hub and spoke model for a proportion of patients with a complex disorder. The service development element is applicable to other future emerging diseases as well as a possible model for conditions that require multiple specialist inputs and can have confused pathways or delays in diagnosis (such as functional disorders or multi-organ pathology).

Inequalities in Access to Care for the London Post Covid Syndrome Pathway for Children and Young People (Cyp)

Aims The London Post COVID Syndrome Pathway was set up in October in 2020 in order to meet the needs of children affected by persistent symptoms after SARS-CoV-2 infection. The UK CLoCk study (1), 11-17 years, showed high symptom prevalence, increasing from time of testing to 3 months (35.4% to 66.5% in SARS-CoV-2 positive cases and 8.3% to 53.3% in controls). ONS (2) data from a large, randomly selected population survey (April 2020 to August 2021) reported symptom prevalence 4-8 weeks after infection of 3.3% in primary aged children (vs 3.6% in negative controls) and 4.6% (vs 2.9%) in secondary aged. The Zoe Kings study (3) showed 1.8% of children had symptoms beyond 8 weeks after infection. The COVID pandemic has affected ethnic minorities and those in deprived communities the most. Here, we aimed to describe referral patterns and ascertain factors influencing inequalities in access to care. Methods We collected demographic and clinical data from our Post COVID clinics, from October 2020 to January 2022. Deprivation deciles were based on the Index of Multiple Deprivation (IMD 2019). Decile 1 represents the most deprived 10% (decile) in England and Decile 10 represents the least deprived 10%. Analyses were descriptive. Results A total of 86 patients were referred with persistent symptoms (median age 14, range 7-18). The female:male ratio was 1.5:1 (52:34). Ethnicity data was available for n=74. Of those 5% identified from Black backgrounds (expected 13.30%);9% Asian (vs 18.50%);12% Other Ethnic Groups (vs 3.40%), 7% Mixed Ethnic Groups (vs 5%) and 53% White (vs 59.80%). Median IMD score was 6, with mode =7 (London mean 3, mode =1). Conclusion Our data suggests children from more affluent (less deprived) areas are accessing the service, with an underrepresentation of males. A small number of patients were referred compared to those reporting persistent symptoms in national surveys. This may be due to a relatively lower number having impairment and/or a lack of awareness amongst professionals. Ethnicity data shows a lower number than expected Black (40% less) and Asian (50% less) backgrounds are accessing support. Since schools re-opened in September 2021 reduced school attendance has been reported for many children. Persistent symptoms are common post viral infection, and most children recover. However, for some these can be debilitating. If children have reduced school attendance due to persistent symptoms they need prompt access to care. Our study raises concern about access to Post COVID services for all children (particularly males and those from minority backgrounds), raising lack of awareness amongst GPs and schools as a possibility. Proactive case finding is needed, particularly in hardly-reached groups. NHS England has recommended a lead for supporting equality to help this and is in post. The numbers of children accessing care is smaller than the number reporting symptoms, an area that requires further study.

Using behavioural science in public health settings during the COVID-19 pandemic: The experience of public health practitioners and behavioural scientists.

INTRODUCTION: The emergence of COVID-19 and the importance of behaviour change to limit its spread created an urgent need to apply behavioural science to public health. Knowledge mobilisation, the processes whereby research leads to useful findings that are implemented to affect positive outcomes, is a goal for researchers, policy makers and practitioners alike. This study aimed to explores the experience of using behavioural science in public health during COVID-19, to discover barriers and facilitators and whether the rapidly changing context of COVID-19 influenced knowledge mobilisation. METHODS: We conducted a semi-structured interview study, with ten behavioural scientists and seven public health professionals in England, Scotland, Wales, The Netherlands and Canada. We conducted an inductive thematic analysis. RESULTS: We report three key themes and 10 sub-themes: 1.Challenges and facilitators of translation of behavioural science into public health (Methods and frameworks supported translation, Lack of supportive infrastructure, Conviction and sourcing of evidence and Embracing behavioural science) 2. The unique context of translation (Rapid change in context, the multi-disciplinary team and the emotional toll). 3. Recommendations to support future behavioural science translation (Embedding experts into teams, Importance of a collaborative network and showcasing the role of behavioural science). DISCUSSION: Barriers and facilitators included factors related to relationships between people, such as networks and teams; the expertise of individual people; and those related to materials, such as the use of frameworks and an overwhelming amount of evidence and literature. CONCLUSION: People and frameworks were seen as important in facilitating behavioural science in practice. Future research could explore how different frameworks are used. We recommend a stepped competency framework for behavioural science in public health and more focus on nurturing networks to facilitate knowledge mobilisation in future emergencies.

Body on fire: Multisystem inflammatory syndrome in children

In April 2020, reports of an inflammatory condition with overlapping features of Kawasaki disease and toxic shock syndrome emerged in Italy and the UK, and subsequently other countries in Europe, the Americas, and Asia have reported cases of this rare syndrome, now called Paediatric Inflammatory Multisystem Syndrome (PIMS-TS) or Multisystem Inflammatory Syndrome in Children (MIS-C), that is temporally associated with SARS-CoV-2 infection. Case definitions use criteria including clinical manifestations (fever, inflammation, organ dysfunction), elevated biochemical markers of inflammation, and evidence of contact or infection with SARS-CoV-2, with exclusion of another microbial cause. There are many questions currently emerging that need to be answered-for example, how the pathophysiology of MIS-C differs from other paediatric conditions such as Kawasaki disease, Kawasaki disease shock syndrome, and toxic shock syndrome. Does the immunology differ from that of severe COVID-19 disease in adults? What are the optimal treatment regimens? Can we improve diagnosis, and hence early recognition and outcomes? In this talk, I will outline the epidemiology, clinical presentation and management, as well as our current understanding of this emerging inflammatory condition.