D.C. Hospital Trying To Understand Rare COVID-19 Complications In Children : NPR

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LULU GARCIA-NAVARRO, HOST:

Anger expressed both as protest and rioting is sweeping over this country as demonstrators decry the death of George Floyd in police custody in Minneapolis as well as historic injustices to do with police violence, inequality and racism against black Americans. We’ll have much more today about this rapidly developing story. But first, to another crisis also gripping America – the pandemic. Now we’re going to bring you into a hospital taking care of kids with rare complications associated with COVID-19.

TARA FLOYD: Yes, we’re good.

GARCIA-NAVARRO: Here at Children’s National in Washington, D.C., they’re trying to understand a mysterious new condition – multisystem inflammatory syndrome in children, or MIS-C. We are the first journalists to have been given access to the pediatric intensive care unit here where the sick are being treated. The littlest patient is only a few weeks old.

I am looking through the glass here to where the COVID kids are, and I can see a really young baby.

MICHAEL BELL: Came in in pretty bad shape yesterday.

GARCIA-NAVARRO: That’s Dr. Michael Bell, chief of critical care, talking about a 6-week-old. Since the onset of COVID-19, the PICU has been transformed. The main quarter where we are is a negative pressure room where the doctors and nurses monitor the patients. Beyond another door is where the children are isolated in a second negative pressure area, kept that way so air and pathogens won’t blow out. Equipment that would normally be inside that patient area is clustered into the small space where we are with Tara Floyd, director of nursing here.

FLOYD: We brought everything out, so it is a little crowded.

GARCIA-NAVARRO: It is crowded and busy. Dr. Bell says they’d been at the epicenter here in the U.S. of COVID-19 infections in children.

BELL: I think Children’s National has seen probably the largest population of kids that I’ve heard about. I think obviously, the district has been relatively hard-hit.

GARCIA-NAVARRO: But MIS-C seemed to come out of nowhere. After reports surfaced in the U.K. in April of the strange new condition, Dr. Bell quickly saw these new patients on his floor. And now…

BELL: We’re following about 45 or 50 kids who we think might have it. But I think we have confirmed something around 30 who convinced have it. It’s definitely a new phenomenon for us. And I think it has a lot of implications that we’re all quite concerned about.

GARCIA-NAVARRO: This is not a common condition. And as we’ve been reporting throughout this pandemic, young children are the least likely of all age groups to become seriously ill with COVID-19. But Dr. Bell says the kids with MIS-C who end up in critical care often have inflammation in their hearts and elsewhere, and doctors don’t know what the long-term effects could be.

BELL: The kid who has the MIS-C, the syndrome, right now is 5. And if she has some terrible swelling from it, which could be coronary arteries that get dilated, and might have heart attacks when she’s 6. That’s going to affect her for 70 years of life expectancy. So the kids have a bigger impact because they’re expected to live a lot longer. So, yes, fewer kids get this. Fewer kids get critically ill with it. But it’s not like there’s not a huge impact of child’s health.

GARCIA-NAVARRO: The good news so far here at Children’s National – there have been no deaths from MIS-C. But so much about this syndrome is still unknown. Dr. Roberta DeBiasi is the chief of pediatric infectious diseases at Children’s National. She says MIS-C is complicated. So far, they’ve seen it manifest in three distinct ways in children. The first, which has gotten a lot of attention, mimics Kawasaki disease, an inflammatory illness in kids.

ROBERTA DEBIASI: They’re kind of the most obvious type. So they may have very high fevers, red eyes, red lips, red tongue. They may have a rash over their body. They may have a swollen lymph node, swelling of their hands and feet.

GARCIA-NAVARRO: And there are signs that may be less obvious to a caregiver or parent of a small child.

DEBIASI: Their primary symptom is really severe abdominal pain. And they may or may not have the red eyes and the red throat and the red tongue and the rash. And then we have a third group, which are really just more non-specific with lots of inflammation and multi-system organ involvement without all of the rash findings.

GARCIA-NAVARRO: Also under investigation – when kids are getting this syndrome.

DEBIASI: Is this acute viral? Is this post-infectious? Is it a combination? We’ve got to figure this out in our patient cohort. And what we’ve found so far in this about 30 kids is the vast majority of them don’t have the virus there. But we do find the antibody in a significant number of them.

So that implies that it is this post-infectious, or after you’ve cleared the virus. And the antibody is there – that this is kind of disregulated (ph) or inappropriate amount of what is usually the right thing your body’s supposed to do, which is make antibody to fight something off.

GARCIA-NAVARRO: Meaning this may be a kid’s immune system overreacting after an active infection. They’re also looking into which kids are getting this and why. There were no reported cases of MIS-C initially in China or on the West Coast of the United States. But the version of the coronavirus on the East Coast tended to come from Europe.

DEBIASI: So we have the European strain. On the West Coast, they have the strain from China imported. So that is one explanation for both the difference in overall hospitalizations and severity in children.

GARCIA-NAVARRO: Or, she wonders…

DEBIASI: Is it something about the population we have here in D.C. or on the East Coast in general? And you’ve probably heard in adults that there does seem to be more infection and severity in some of the racial or ethnic groups or perhaps even genetic predispositions to COVID.

GARCIA-NAVARRO: But Dr. DeBiasi suspects the answer may be simpler.

DEBIASI: These children have now been living in a community where there’s ongoing exposure, and they’ve probably been re-exposed once or even maybe twice. But I think what’s happening here is these kids that are being re-exposed out in the community to a virus that they saw and made an appropriate immune response to initially – that immune response is just inappropriately revved up.

GARCIA-NAVARRO: So it’s like you might not be allergic to a bee the first time it stings you. But the second time it stings you…

DEBIASI: Exactly.

GARCIA-NAVARRO: You’ll have an allergic reaction.

DEBIASI: Exactly. So that may be one of the explanations that make the most sense. But really, we don’t know what the reason is.

UNIDENTIFIED PERSON #1: We’ve been trying to clear a lot of them.

(CROSSTALK)

UNIDENTIFIED PERSON #1: …Pretty good.

GARCIA-NAVARRO: The medical staff here is trying to figure all this out in real time. Over a dozen doctors and specialists, some dialing in remotely, are gathered in a conference room in a different isolation ward at Children’s National.

UNIDENTIFIED PERSON #2: I think you should look for an alternative diagnosis. And obviously, if the kids’ lapse escalated or de-escalated…

GARCIA-NAVARRO: They meet every day. In this area, the less critical cases of MIS-C are being treated. The CDC has issued broad guidelines for what can be diagnosed as multisystem inflammatory syndrome in children. But because the condition is so new, the team here want to be sure that the diagnosis is right. Part of the team Dr. Laura O’Neill says it’s a process of elimination.

LAURA O’NEILL: So there’s a lot of diagnostic uncertainty with most of these patients. We really struggle with trying to figure out what else could be going on with them just to make sure we’re not missing what is usually a more common diagnosis for them that could easily be treated either with antibiotics or other medications. So I think, for me, that’s the hardest thing about this – is really having to think really hard all the time about every single patient who comes in with this and making sure we’re doing due diligence.

GARCIA-NAVARRO: Dr. Matthew Magyar adds they’ve been successful in treating many cases of MIS-C, but they’re cautious about diagnosing it because the treatments involved can put such a strain on growing bodies.

MATTHEW MAGYAR: We don’t necessarily know, so we have to be very conservative and manage things to make sure we don’t go too fast to a more dangerous course.

GARCIA-NAVARRO: Still, here at Children’s, the majority of cases end up not becoming critical, unlike in the U.K. and even New York, says Dr. Karen Smith, chief of hospital medicine here. And most end up in this non-critical ward.

KAREN SMITH: And really actually here, we’ve been able to keep about two-thirds on the floor. You know, we really have a way of, OK, identifying them early, treating them early so that kids don’t get sicker.

GARCIA-NAVARRO: But the treatment of each of these little patients takes an enormous amount of resources. Children’s National has multiple areas dealing with COVID-19 and MIS-C, which requires huge amounts of equipment and staffing.

(CROSSTALK)

GARCIA-NAVARRO: Back at the pediatric ICU, to give you a sense of how much work this all takes, this is the elaborate process of what is called donning and doffing. It’s something every nurse, specialist and doctor has to go through every time they go in or out of the room of a patient with COVID or a child with MIS-C. And they have to go in a lot.

There are gowns and gloves, of course. And instead of the N95 mask here, the doctors and nurses in the patient’s room wear something called a papper (ph). It’s kind of like a white bicycle helmet with a shield and its own ventilation system so it can be worn comfortably for up to four hours.

O’NEILL: Are you ready to come out? Did you clean the door and the Purell?

GARCIA-NAVARRO: When it’s time to open the door, the nurse makes sure everyone in the hallway is protected from the air that might flow out of the room.

UNIDENTIFIED PERSON #3: Wait. Wait. Wait. Wait. Wait. Wait. Wait. Wait. Hold on. Does everyone have a mask on?

GARCIA-NAVARRO: A doctor emerges and stands in a designated spot marked by orange tape. A buddy who’s a nurse is right there directing them through the sanitary protocols when doffing or taking off their PPE. This is the most dangerous part, when infected material could get passed on. And it’s hard to be socially distant in this cramped hallway.

UNIDENTIFIED PERSON #3: So take off your gloves and Purell. Go ahead and turn around. Can you step back for a second, Mike (ph)?

GARCIA-NAVARRO: So far, though, none of the health care workers in the pediatric ICU have gotten sick. While outside this hospital, the country rages about opening up and wearing masks and how serious COVID-19 and its effects really are, here, time is punctuated by beeps and bustle. Everything is focused on one mission – to keep children alive.

BELL: Every pediatric ICU doctor, I think, tries to take care of every kid as if they’re their own.

GARCIA-NAVARRO: Dr. Michael Bell, the pediatric ICU’s chief of critical care, hasn’t seen his family in 11 weeks. He jokes with Tara Floyd, the head nurse.

BELL: We have a few saying that we’re going to make T-shirts on. It’s – I forget all the sayings, but Tara knows them.

FLOYD: Positive vibes, negative pressure.

BELL: Right. We like that one.

FLOYD: Or negative pressure, positive outcomes. So we’re prepared to do whatever we need to do to keep the kids safe and, you know, get things back to normal as much as we can. But it’s been a challenging year.

GARCIA-NAVARRO: Elsewhere in the program, a boy who’s had multisystem inflammatory syndrome in children, what his mom saw that made her pay attention and her advice to other parents.

(SOUNDBITE OF MUSIC)

GARCIA-NAVARRO: Our stories from Children’s National Hospital were produced by Peter Breslow and edited by Ed McNulty.

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