Dr. Sarah Ash Combs’ first step in treating children who were brought into her emergency room with Covid-19 usually begins with a question: “What socks are you wearing today?”
Dr. Sarah Ash Combs’ first step in treating children brought into her emergency room with Covid-19 usually begins with a question: “What socks are you wearing today?”
As her school-age young patients look up at indistinguishable faces covered in PPE, Combs pulls a trouser leg out of her scrub to show off her own socks. Sometimes they are inconsistent, sometimes they are covered by animals. And if she has her favorite on, they have sushi.
The increase in Covid-19 cases caused by the highly transmissible Delta variant has meant an increase in admissions among children — many of whom are not yet eligible for a vaccine. Nearly 26% of all Covid-19 cases nationwide reported in children according to recent data published by American Academy of Pediatrics. And about 290 children are hospitalized with Covid-19 every day, according to Sunday’s data from American Centers for Disease Control and Prevention.
The relentless nature of the pandemic has overwhelmed health professionals across the country. And for those in pediatric care, they have had to overcome many new obstacles. For some, it makes children feel comfortable in a scary environment. For others, navigating the stress of a child’s diagnosis is on top of the family’s financial insecurities. And many providers struggle to customize virtual visits for patients who may not always be able to describe how they feel.
“I’m here to work with people, work with children, treat them, make them feel better in the full sense of the word,” Combs said. “If that means I have to wear sparkling socks that don’t match each other and have a big mark with my face a little too close and speak really loud in crazy tones, then I do.”
For the pediatrician, the pandemic has been fraught with emotional considerations.
She returned to the emergency room at Children’s National Hospital in Washington, DC, from childbirth with her first child in early May 2020, she said. At the beginning of the pandemic, she found herself in a whole new way in relation to the parents of her pediatric patients.
On her first day, she remembers saying goodbye to her husband and 2-month-old and feeling scared for the first time, she said.
The same day, a mother brought in a 2-month-old patient who tested positive for Covid. Combs sat with her in the midst of anxiety and insecurity. When a child comes in with an ear infection, she could typically rely on years of experience and reassure the parents by telling them exactly what to expect, but this virus was something the medical community knew little about.
Fortunately, she said the baby recovered and was well.
But while some interactions with families left her more connected, others were fraught with tension, she said. For much of the pandemic, only one parent could stay with their hospitalized child, sometimes resulting in fear, grief, and anger.
“This was one of the most blurred lines I’ve ever felt,” Combs said as she explained the pain of not being able to embrace grieving parents with a hug.
Combs said she knew she had to respond with the logical reason and detailed the rules and importance of infection control.
“But inside, I died emotionally a little bit because I so viscerally felt exactly what they were going through,” she said. “God forbid, I could not imagine if my 2-month-old would need anything and be there alone for days.”
‘Will my child die?’
Dr. Sanchita Sharma is the one who gets called up when things get tough.
As a clinical psychologist at Children’s National, doctors treating children with Covid-19 will often bring her in when a child’s infection also raises mental concerns.
When the pandemic broke out, it quickly became clear that it was hurting families in particular who were struggling financially, she said.
Those in lower socioeconomic groups are particularly vulnerable to infection, Sharma noted. So on top of behavioral problems and diagnoses for herself, she helps many children cope with the trauma of watching a loved one die in the pandemic, she said.
“Virtually every patient I see now has had someone die in their home from Covid,” Sharma said.
And the pandemic has made financial worries associated with illness even more stressful for families – many of whom depend on their children having time in school or day care to work.
“When a child gets the diagnosis, they get quarantined from day care centers right … that means a parent has to stay at home with them, and what does that mean – financially, financially – for the family?” Said Sharma.
For black families, there is also distrust of the medical community, born of a history of neglect and abuse.
“It’s the fear that my child will die?” that Sharma says that the parents express for her. “I have it and want my black child to get the care they need.”
It has become more important than ever to approach conversations with parents not as an authority, but as someone who can help explain what the pandemic means to their children and what they can do next, she said. Part of it may even mean helping parents deal with their own mental health.
“Their mental health is directly related to their child’s mental health will be like,” Sharma said. “Check in with yourself, see if you’ve felt anxious, see if you’ve felt stressed over everything, and then you might notice that your child may pick up on something himself.”
Simon Says and baby doll for physical examinations
During the pandemic, Dr. Alicia Johnston’s work involved many more baby dolls and games by Simon Says.
Johnston is a pediatrician of Infectious Diseases at Boston Children’s Hospital, where she works in an interdisciplinary clinic for children with Long Covid.
As many families are wary of traveling or going into offices, Johnston holds several virtual visits to the families.
It has helped children feel more secure, opened access to more families and enabled caregivers to focus on their conversation with the health care provider while their child plays or sleeps at home, she said.
But there are real obstacles.
“Obviously, there are many, many limitations to trying to do a physical examination in a two-dimensional format without being able to put a stethoscope on a child’s breast and actually palpate a limb and abdomen,” Johnston said.
So she’s gotten creative, plays Simon Says over the camera to undergo a neurological examination, asks parents to hold a phone flashlight to their child’s open mouth, and uses baby dolls to show parents what she wants them to do with their infant exam.
The biggest innovation in her work, however, is the collaboration with specialists who come together to treat children who are still facing symptoms after clearing the infection.
At her clinic, Johnston can offer many physicians who work together to treat the symptoms. And despite the lack of information about Long Covid in children, she can give recognition that what their children are going through is genuine.
“It’s a great deal of comfort for patients and parents to know that they are being heard,” she said.
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