Impact of COVID-19 Pandemic on Developmental Service Delivery in Children With a History of Neonatal Seizures.

BACKGROUND: Children with a history of acute provoked neonatal seizures are at high risk for disability, often requiring developmental services. The coronavirus disease 2019 (COVID-19) pandemic has led to widespread changes in how health care is delivered. Our objective was to determine the magnitude of service interruption of among children born between October 2014 and December 2017 and enrolled in the Neonatal Seizure Registry (NSR), a nine-center collaborative of pediatric centers in the United States. METHODS: This is a prospective cohort study of children with acute provoked seizures with onset ≤44 weeks' gestation and evaluated at age three to six years. Parents of children enrolled in the NSR completed a survey about their child's access to developmental services between June 2020 and April 2021. RESULTS: Among 144 children enrolled, 72 children (50%) were receiving developmental services at the time of assessment. Children receiving services were more likely to be male, born preterm, and have seizure etiology of infection or ischemic stroke. Of these children, 64 (89%) experienced a disruption in developmental services due to the pandemic, with the majority of families (n = 47, 73%) reporting that in-person services were no longer available. CONCLUSIONS: Half of children with acute provoked neonatal seizures were receiving developmental services at ages three to six years. The COVID-19 pandemic has led to widespread changes in delivery of developmental services. Disruptions in services have the potential to impact long-term outcomes for children who rely on specialized care programs to optimize mobility and learning.

Association of the COVID-19 Pandemic With Routine Childhood Vaccination Rates and Proportion Up to Date With Vaccinations Across 8 US Health Systems in the Vaccine Safety Datalink.

Importance: The COVID-19 pandemic has affected routine vaccine delivery in the US and globally. The magnitude of these disruptions and their association with childhood vaccination coverage are unclear. Objectives: To compare trends in pediatric vaccination before and during the pandemic and to evaluate the proportion of children up to date (UTD) with vaccinations by age, race, and ethnicity. Design, Setting, and Participants: This surveillance study used a prepandemic-postpandemic control design with data from 8 health systems in California, Oregon, Washington, Colorado, Minnesota, and Wisconsin in the Vaccine Safety Datalink. Children from age groups younger than 24 months and 4 to 6, 11 to 13, and 16 to 18 years were included if they had at least 1 week of health system enrollment from January 5, 2020, through October 3, 2020, over periods before the US COVID-19 pandemic (January 5, 2020, through March 14, 2020), during age-limited preventive care (March 15, 2020, through May 16, 2020), and during expanded primary care (May 17, 2020, through October 3, 2020). These individuals were compared with those enrolled during analogous weeks in 2019. Exposures: This study evaluated UTD status among children reaching specific ages in February, May, and September 2020, compared with those reaching these ages in 2019. Main Outcomes and Measures: Weekly vaccination rates for routine age-specific vaccines and the proportion of children UTD for all age-specific recommended vaccines. Results: Of 1 399 708 children in 2019 and 1 402 227 in 2020, 1 371 718 were female (49.0%) and 1 429 979 were male (51.0%); 334 216 Asian individuals (11.9%), 900 226 were Hispanic individuals (32.1%), and 201 619 non-Hispanic Black individuals (7.2%). Compared with the prepandemic period and 2019, the age-limited preventive care period was associated with lower weekly vaccination rates, with ratios of rate ratios of 0.82 (95% CI, 0.80-0.85) among those younger than 24 months, 0.18 (95% CI, 0.16-0.20) among those aged 4 to 6 years, 0.16 (95% CI, 0.14-0.17) among those aged 11 to 13 years, and 0.10 (95% CI, 0.08-0.13) among those aged 16 to 18 years. Vaccination rates during expanded primary care remained lower for most ages (ratios of rate ratios: <24 months, 0.96 [95% CI, 0.93-0.98]; 11-13 years, 0.81 [95% CI, 0.76-0.86]; 16-18 years, 0.57 [95% CI, 0.51-0.63]). In September 2020, 74% (95% CI, 73%-76%) of infants aged 7 months and 57% (95% CI, 56%-58%) of infants aged 18 months were UTD vs 81% (95% CI, 80%-82%) and 61% (95% CI, 60%-62%), respectively, in September 2019. The proportion UTD was lowest in non-Hispanic Black children across most age groups, both during and prior to the COVID-19 pandemic (eg, in May 2019, 70% [95% CI, 64%-75%] of non-Hispanic Black infants aged 7 months were UTD vs 82% [95% CI, 81%-83%] in all infants aged 7 months combined). Conclusions and Relevance: As of September 2020, childhood vaccination rates and the proportion who were UTD remained lower than 2019 levels. Interventions are needed to promote catch-up vaccination, particularly in populations at risk for underimmunization.

Home-Based Telemental Health: A Proposed Privacy and Safety Protocol and Tool.

Objectives: To describe the development of a protocol and practical tool for the safe delivery of telemental health (TMH) services to the home. The COVID-19 pandemic forced providers to rapidly transition their outpatient practices to home-based TMH (HB-TMH) without existing protocols or tools to guide them. This experience underscored the need for a standardized privacy and safety tool as HB-TMH is expected to continue as a resource during future crises as well as to become a component of the routine mental health care landscape. Methods: The authors represent a subset of the Child and Adolescent Psychiatry Telemental Health Consortium. They met weekly through videoconferencing to review published safety standards of care, existing TMH guidelines for clinic-based and home-based services, and their own institutional protocols. They agreed on three domains foundational to the delivery of HB-TMH: environmental safety, clinical safety, and disposition planning. Through multiple iterations, they agreed upon a final Privacy and Safety Protocol for HB-TMH. The protocol was then operationalized into the Privacy and Safety Assessment Tool (PSA Tool) based on two keystone medical safety constructs: the World Health Organization (WHO) Surgical Safety Checklist/Time-Out and the Checklist Manifesto.Results: The PSA Tool comprised four modules: (1) Screening for Safety for HB-TMH; (2) Assessment for Safety During the HB-TMH Initial Visit; (3) End of the Initial Visit and Disposition Planning; and (4) the TMH Time-Out and Reassessment during subsequent visits. A sample workflow guides implementation. Conclusions: The Privacy and Safety Protocol and PSA Tool aim to prepare providers for the private and safe delivery of HB-TMH. Its modular format can be adapted to each site's resources. Going forward, the PSA Tool should help to facilitate the integration of HB-TMH into the routine mental health care landscape.

How Telehealth Can be Used to Improve Maternal and Child Health Outcomes: A Population Approach.

Mobile applications and telehealth services are being used to unprecedented degrees in maternal and child care, with uncertain impact on population health outcomes. In this article, we will review the role of the COVID-19 pandemic in accelerating large scale implementation of telehealth services, known and anticipated impacts on maternal and child health and related inequities, and potential strategies to optimize outcomes at the population level.

Evaluating Neonatal Telehealth Programs Using the STEM Framework.

The COVID-19 pandemic has caused an explosive adoption of telehealth in pediatrics . However, there remains substantial variation in evaluation methods and measures of these programs despite introduction of measurement frameworks in the last five years. In addition, for neonatal health care, assessing a telehealth program must measure its benefits and costs for four stakeholder groups - patients, providers, healthcare system, and payers. Because of differences in their role within the health system, each group's calculation of telehealth's value may align or not with one another, depending on how it is being used. Therefore, a common mental model for determining value is critical in order to use telehealth in ways that produce win-win situations for most if not all four stakeholder groups. In this chapter, we present important principles and concepts from previously published frameworks to propose an approach to telehealth evaluation that can be used for perinatal health. Such a framework will then drive future development and implementation of telehealth programs to provide value for all relevant stakeholders in a perinatal health care system.

Wellbeing of CAMHS staff and changes in working practices during the COVID-19 pandemic.

INTRODUCTION: The coronavirus disease 2019 pandemic has necessitated significant changes in working practices across healthcare services. The current study aimed to assess the wellbeing of health professionals and quantify the adaptations to working practices in a Child and Adolescent Mental Health Service (CAMHS) during the pandemic. METHOD: The study was conducted in a UK CAMH team six weeks into lockdown measures. All clinicians were invited to complete a survey eliciting their experiences of working practices during the pandemic, degree of worry about the virus and mental wellbeing. RESULTS: Clinicians had significantly lower levels of mental wellbeing during the pandemic than population normative data, to the extent that some clinicians were classified as at heightened risk of depression. A significant shift to remote working, reduction in face-to-face appointments, and decrease in clinicians' perceived ability to undertake clinical tasks was observed. Themes emerging from clinicians' experiences of working during the pandemic include being supported within the team, providing a service, working adaptations, and working as a team. A further theme highlights the needs of clinicians to complete their clinical role effectively. CONCLUSION: CAMHS clinicians require additional support, training, and guidance during a pandemic to promote mental wellbeing and effectiveness in completing clinical tasks.

Child health services during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Current evidence indicates that children are relatively spared from direct COVID-19-related morbidity and mortality, but that the indirect effects of the pandemic pose significant risks to their health and wellbeing. OBJECTIVES: To assess the impact of the local COVID-19 outbreak on routine child health services. METHODS: The District Health Information System data set for KwaZulu-Natal (KZN) provincial health services was accessed, and monthly child health-related data were extracted for the period January 2018 - June 2020. Chronological and geographical variations in sentinel indicators for service access, service delivery and the wellbeing of children were assessed. RESULTS: During April - June 2020, following the start of the COVID-19 outbreak in KZN, significant declines were seen for clinic attendance (36%; p=0.001) and hospital admissions (50%; p=0.005) of children aged <5 years, with a modest recovery in clinic attendance only. Among service delivery indicators, immunisation coverage recovered most rapidly, with vitamin A supplementation, deworming and food supplementation remaining low. Changes were less pronounced for in- and out-of-hospital births and uptake rates of infant polymerase chain reaction testing for HIV at birth, albeit with wide interdistrict variations, indicating inequalities in access to and provision of maternal and neonatal care. A temporary 47% increase in neonatal facility deaths was reported in May 2020 that could potentially be attributed to COVID-19-related disruption and diversion of health resources. CONCLUSIONS: Multiple indicators demonstrated disruption in service access, service delivery and child wellbeing. Further studies are needed to establish the intermediate- and long-term impacts of the COVID-19 outbreak on child health, as well as strategies to mitigate these.

Building a Community Partnership in a Pandemic: NJ Pediatric Residency Advocacy Collaborative.

The New Jersey Pediatric Residency Advocacy Collaborative (NJPRAC) is a statewide collaborative with faculty leads from each of the 10 New Jersey pediatric residency programs. The 2 major goals of the collaborative were to build community partnerships between pediatric residency programs and local organizations and develop a core advocacy curriculum. In this article, we focus on how the NJPRAC built community partnerships with Family Success Centers (FSCs) across the state over the course of a 2-year period. FSCs are located within every county in the state and fall under the New Jersey Department of Children and Families, providing resources and supports for families in crisis, with a focus on child abuse prevention services. Amid this growing partnership, the coronavirus disease 2019 (COVID-19) pandemic forced the NJPRAC to swiftly pivot its partnership and develop innovative programs to support families during the COVID-19 pandemic. As FSC leadership communicated families' concerns to the collaborative, we initiated the Virtual House Call webinar, which incorporated pediatricians, community leaders, and allied health professionals to answer COVID-19 questions. These webinars quickly expanded into weekly interprofessional series, with experts in mental health, law, nutrition, and dentistry partnering with pediatricians from various subspecialties. Key to the webinars' success was responding in real time to audience questions, collaborating with the FSC leadership on content, and garnering the support from the local New Jersey Chapter, American Academy of Pediatrics and the national American Academy of Pediatrics. A key challenge remains to meaningfully incorporate pediatric trainees into community partnerships. The NJPRAC plans to continue the Virtual House Call series with continuous input from the FSCs and participating families.

Rapid Implementation of Telehealth Services in a Pediatric Pulmonary Clinic During COVID-19.

OBJECTIVES: The coronavirus pandemic created significant, abrupt challenges to the delivery of ambulatory health care. Because tertiary medical centers limited elective in-person services, telehealth was rapidly enacted in settings with minimal previous experience to allow continued access to care. With this quality improvement (QI) initiative, we aimed to achieve a virtual visit volume of at least 75% of our prepandemic volume. We also describe patient and provider experience with telehealth services. METHODS: Our QI team identified the primary drivers contributing to low telehealth volume and developed a telehealth scheduling protocol and data tracking system using QI-based strategies. Patients and providers were surveyed on their telehealth experience. RESULTS: At the onset of the pandemic, weekly visit volume dropped by 65% (99 weekly visits; historical average of 281). Over the subsequent 3 weeks, using rapid Plan-Do-Study-Act cycles, we achieved our goal volume. In surveys, it was indicated that most participants had never before used telehealth (71% of patients; 82% of providers) yet reported high satisfaction (90% of patients; 81% of providers). Both groups expressed concern over the lack of in-person assessments. Most respondents were interested in future use of telehealth. CONCLUSIONS: With a QI-based approach, we successfully maintained access to care via telehealth services for pediatric pulmonary patients during the coronavirus pandemic and found high rates of satisfaction among patients and providers. Telehealth will likely continue to be a part of our health care delivery platform, expanding the reach of our services. Further work is needed to understand the effects on clinical outcomes.

Telehealth in pediatric primary care.

Telehealth in the broadest sense has been used by pediatric clinicians for over a century, as telephone triage has been and continues to be an essential part of pediatric practice. Utilizing more advanced technology including video communication, although available, was generally underutilized until the onset of the COVID-19 pandemic. Telehealth presents the opportunity to bridge many divides including geographical and logistical challenges. Many acute pediatric conditions can be managed safely and effectively through telehealth especially when remote physical exam equipment is used. Telehealth can also be especially useful in medical care of children with medical complexity. Traveling with medical equipment to multiple subspecialists can be incredibly challenging and often a similar quality visit can be conducted through telehealth in the comfort of a child's home environment. Well child care presents a unique problem while trying to maintain social distancing. Integrating a hybrid model using both an in-person exam and history through video conferencing can help balance limited face to face time with the need to ensure a full and appropriate physical exam. Integration of telehealth into the pediatric patient centered medical home can enable families to gain convenience while maintaining the essential relationship with their primary care office.

The Impact of the Novel Coronavirus Disease 2019 on Therapy Service Delivery for Children with Disabilities.

OBJECTIVE: To assess the impact of the novel coronavirus disease 2019 (COVID-19) pandemic on the delivery of, and parent satisfaction with, therapy services for children with disabilities in early intervention, school, and outpatient settings. STUDY DESIGN: There were 207 parents of children with disabilities who completed a web-based survey about their child[ren]'s access to, and satisfaction with, therapy services during COVID-19. Parents also completed the Family-Provider Partnership Scale and the Telehealth Satisfaction Scale. Satisfaction was compared between families receiving therapies in school, early intervention, outpatient, and multiple settings. RESULTS: Forty-four percent of parents reported low satisfaction with their child[ren]'s therapy services during the pandemic. Access to telehealth positively predicted overall satisfaction and satisfaction with the family-provider partnership, whereas receiving school-based therapies negatively predicted overall satisfaction and satisfaction with the family-provider partnership. CONCLUSIONS: School-based therapies are legally mandated for eligible students, free of cost to families, integrated in the academic setting, and less burdensome on parents than other services. Thus, given the disparity in parental satisfaction regarding school-based service delivery, addressing therapy delivery in school-based settings during the duration of COVID-19 is critical for preventing increased disparities and more effectively meeting children's needs. Telehealth seems to be a promising option for continuing high-quality services during the duration of the COVID-19 pandemic and for families who face barriers in accessing services in general. Future studies are warranted with larger and more diverse samples, as well as longitudinal studies that monitor service access and parent satisfaction throughout the remainder of the pandemic.

Child health services during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Current evidence indicates that children are relatively spared from direct COVID-19-related morbidity and mortality, but that the indirect effects of the pandemic pose significant risks to their health and wellbeing. OBJECTIVES: To assess the impact of the local COVID-19 outbreak on routine child health services. METHODS: The District Health Information System data set for KwaZulu-Natal (KZN) provincial health services was accessed, and monthly child health-related data were extracted for the period January 2018 - June 2020. Chronological and geographical variations in sentinel indicators for service access, service delivery and the wellbeing of children were assessed. RESULTS: During April - June 2020, following the start of the COVID-19 outbreak in KZN, significant declines were seen for clinic attendance (36%; p=0.001) and hospital admissions (50%; p=0.005) of children aged <5 years, with a modest recovery in clinic attendance only. Among service delivery indicators, immunisation coverage recovered most rapidly, with vitamin A supplementation, deworming and food supplementation remaining low. Changes were less pronounced for in- and out-of-hospital births and uptake rates of infant polymerase chain reaction testing for HIV at birth, albeit with wide interdistrict variations, indicating inequalities in access to and provision of maternal and neonatal care. A temporary 47% increase in neonatal facility deaths was reported in May 2020 that could potentially be attributed to COVID-19-related disruption and diversion of health resources. CONCLUSIONS: Multiple indicators demonstrated disruption in service access, service delivery and child wellbeing. Further studies are needed to establish the intermediate- and long-term impact of the COVID-19 outbreak on child health, as well as strategies to mitigate these.

Priorities for the child public health response to the COVID-19 pandemic recovery in England.

Child health is at risk from the unintended consequences of the COVID-19 response and will suffer further unless it is given proper consideration. The pandemic can be conceived as a systemic shock to the wider determinants of child health, with impacts on family functioning and income, access to healthcare and education. This article outlines COVID-19 impacts on children in England. Key priorities relate to the diversion of healthcare during lockdown; interruption and return to schooling; increased health risks and long-term impacts on child poverty and social inequalities. We provide an overview of mitigation strategies and policy recommendations aimed to assist both national and local professionals across child health, education, social care and related fields to inform the policy response.

Developing new models of care at speed: learning from healthcare redesign for children with COVID-related multisystem inflammation.

This article describes the rapid, system-wide reconfiguration of local and network services in response to the newly described paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) (also known as multisystem inflammatory syndrome in children). Developing the model of care for this novel disease, whose natural history, characteristics and treatment options were still unclear, presented distinct challenges.We analyse this redesign through the lens of healthcare management science, and outline transferable principles which may be of specific and urgent relevance for paediatricians yet to experience the full impact of the COVID-19 pandemic; and more generally, for those developing a new clinical service or healthcare operating model to manage the sudden emergence of any unanticipated clinical entity. Health service leaders in areas where COVID-19 is, or will soon be, in the ascendancy, and who are anticipating the imminent influx of PIMS-TS, should use these principles and recommendations to plan an agile, responsive and system-wide model of care for these children.

Debate: Supporting the mental health of school students in the COVID-19 pandemic in New Zealand - a digital ecosystem approach.

The pandemic is creating unprecedented demand for mental health support for young people. While schools often facilitate mental health support for their students, the demands for online teaching and the uncertainty created by the pandemic make traditional delivery of support through schools challenging. Technology provides a potential way forward. We have developed a digital ecosystem, HABITS, that can be integrated into school and healthcare systems. This has allowed us to deploy specific evidence-based interventions directly, and through schools, to students and to parents in New Zealand during the current pandemic. Chatbot architecture is particularly suited to rapid iteration to provide specific information while apps can provide more generalised support. While technology can provide some solutions, it is important to be aware of the potential to increase current inequities, with those facing the greatest challenges to health and well-being, also least able to afford the resources to access digital interventions. Development of an integrated and equitable digital system will take time and collaboration.