Weeks before health officials acknowledged that children were developing life-threatening immune responses to COVID-19, Dr. James Schneider’s ICU was already knee-deep in cases. He was one of the first front line pediatricians to go on the record about what he was seeing.
On May 1, he told NBC New York "It just goes to show that COVID doesn’t spare any age group." Dr. Schneider is Director of Critical Care at Cohen Children’s Hospital in Nassau County, which has treated more MIS-C cases than any other hospital in the region.
Since the New York State Department of Health started collecting information from hospitals on May 5, Cohen Children’s Hospital has reported 43 cases of the inflammatory sickness to state health officials. Now, Dr. Schneider tells Melissa Russo treating the condition is just "good old fashioned critical care."
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Q: Fill us in on how things are going. Are you still getting these patients, and if so is it still a steady stream?
A: We are still getting some patients. I think the initial surge of these very sick patients seems to be a little less now, but we do get at least on a daily basis a few children who we are evaluating for this syndrome. The acute infections have come down, thankfully, and now, this surge of MIS-C patients seems to be at least on the downswing, which is kind of mirroring the curve.
It’s encouraging that hopefully things will continue to slowly get better. There are a handful in the hospital as we speak. But thankfully, they all continue to do well. They respond to the therapies that we’re giving and they’re going home.
Q: What is most challenging about treating these children with MIS-C?
A: The medical side of it, frankly, is not particularly challenging to an experienced ICU.
It’s really what I call good old fashioned critical care. Kids need blood pressure support, breathing support, and that’s something we do on a routine basis. So that stuff is fairly manageable without any added stress.
And then the other part of the treatment is the classic tried and true treatment for Kawasaki’s disease (intravenous immunoglobulin or IVIG as well as aspirin and steroids).
Clearly, the families have a lot of appropriate level of concern and anxiety around the diagnosis. Their children are super sick. Now that the word is getting out, people are worried, but we try to reassure them with our data that show kids do well.
We’re in a big, very busy, tertiary children’s hospital ICU so sick kids in general actually get us more engaged and interested it doesn’t scare people away, that’s for sure.
Q: In what age range are you seeing the most cases?
A: As we start to gather and collect data as a community, then we’ll be able to be more specific. But for now, it seems that our median age is the 8-year-old range, which is a little older than what we typically see for Kawasaki disease.
So I’d say 8-year-olds to early teens are the typical range we’re seeing. And so of course, these are children who are more cognitively aware and can participate in the conversation of their care, but we’re pretty used to that.
Q: What’s the hardest part for a child going through MIS-C and how do you make this less scary for kids?
A: As you can imagine any time there are needle pokes, that can cause a lot of anxiety. In an older child if we have to intubate them we will talk to them and tell them why we are doing and sometimes it’s taken very well but sometimes it takes more support from our team and a parent.
Kids themselves are a different type of patient than adults. Sometimes it’s harder to treat the adults, i.e. the parents and family members, rather than the child. It’s very much a multidisciplinary effort in the ICU, treating a child. So the medical side of it is often the easy part, in terms of what medicines to choose. But based the age, the cognitive level of a child, the emotional development of a child, there are lots of different things that are also needed. So we have a very active music therapy, art therapy program and our social workers are very active. Everyone is doing the work which helps get these kids emotionally through this hospitalization.
Q: Do you think that the incidence of this pediatric syndrome is high enough that it will have to inform decision-making about things like camp and school?
A: I knew you were going to ask that. So the emergence of this new condition, I think it will add to the discussion, because we do not have a known way to prevent this other than preventing primary infection with COVID-19. It just adds to the picture, but i don’t think it changes it that much. What it does do, it helps to remind us that kids are not immune to this infection, whereas early on, the academics thought that kids don’t really get this. We do still know that kids most commonly are either asymptomatic or very mildly affected when they are acutely ill with Coronavirus infection, but it doesn’t seem that they are completely immune and it is definitely something to consider. I think it lends to the narratives but I don’t think it’s gonna be the number one thing that changes the minds of the policy makers.
There’s a big concern for all of us that as regulations loosen and we start getting back into the community that we are gonna start seeing a real significant uptick.
Personally, I’m quite concerned because just even over the weekend, there are way too many people I think, out there walking around with no masks, not maintaining social distancing. I share the concern of many of my colleagues that we are gonna start to see another resurgence of acute patients. I hope not. I hope we’re wrong but we have to be prepared for it. I’m also an administrator in an ICU and I have to prepare my group.
Q: What is happening in a child’s body that causes the particular symptoms we are seeing?
A: In general, this syndrome is considered a post-infectious inflammatory response. meaning the body is creating an immune response to fight off in this case the coronavirus.
In the process, it leads to an overactive immune system, which leads to inflammation or irritation of blood vessels of the body. It also can lead to direct irritation or inflammation of the heart muscle itself. And the combination leads to lower blood pressure, because either the blood vessels are enlarged or dilated, or the heart muscle itself is weakened and so a response we see is a heart beating faster to try to deliver enough oxygen and nutrients to all the tissue of the body. So what we see on the outside of the body, we’ve been noticing a red rash, sometimes red injected eyes, red cracked lips or a very red tongue. that’s all evidence of irritation or inflammation of blood vessels or what we call vasculitis and they just happen to be on the surface so we can see it.