The ACR has released new clinical guidance for pediatric patients with rheumatic disease in the context of the COVID-19 pandemic. Jay Mehta, MD, an attending physician in the Division of Rheumatology and director of the Pediatric Rheumatology Fellowship at the Children’s Hospital of Philadelphia (CHOP), chaired the task force charged with developing the guidance.
The majority of serious and life-threatening outcomes of COVID-19 have occurred in adults, and in April the ACR released clinical guidance for the care of adult patients with rheumatic diseases during the pandemic. In the earlier stages of the pandemic, it appeared children were less likely to develop severe manifestations of SARS-CoV-2. But as case reports accumulated of children exhibiting multisystem inflammatory syndromes with features similar to Kawasaki disease, the ACR decided to develop pediatric-focused clinical guidance as well, Dr. Mehta says. It made sense, he reasoned, to set up two task forces: one to address clinical guidance for pediatric patients with rheumatic disease, and another to provide guidance regarding children with multisystem inflammatory syndrome (MIS-C) associated with SARS-CoV-2 and hyperinflammation in COVID-19.
Dr. Jay Mehta
Dr. Mehta and his two lead task force physicians recently shared the processes they followed for their work, which took place over a very short period of time, from mid-May to mid-June. Characterized by even-handed and reassuring language, both guidance documents have now been submitted to Arthritis & Rheumatology and are undergoing review. In addition, Dr. Mehta notes, the guidance documents are very much living documents and will be revisited and updated as evidence evolves.
Evaluating Evidence
Dawn M. Wahezi, MD, associate professor in the Department of Pediatrics and division chief in Pediatric Rheumatology, Children’s Hospital at Montefiore, The Bronx, N.Y., was selected to lead the ACR COVID-19 Pediatric Rheumatology Clinical Guidance Task Force. The Bronx was one of the first pandemic hot spots in the U.S., and Dr. Wahezi was chosen in part due to her direct experience with the virus. Following her initial conversation with Dr. Mehta, Dr. Wahezi recalls that “everything happened fairly quickly.” When inviting possible task force participants, she says, “we intentionally included pediatric rheumatologists from across the country [with varied] expertise and from areas with [varying] prevalence of COVID-19.”
She and Dr. Mehta drafted general, clinical questions based on issues they and other providers had encountered with patients, families and other providers. Evidence to date is limited, she notes, so they also looked to the Centers for Disease Control & Prevention and other online sources for clinical questions to address.
Dr. Dawn Wahezi
Those questions were proposed to task force participants—comprising seven pediatric rheumatologists, two pediatric infectious disease physicians, one adult rheumatologist and one pediatric nurse practitioner—during a webinar on May 21. Participants voted anonymously on the initial questions using a 1 to 9 rating scale (1 = disagree; 9 = agree). The statements were refined through two more rounds of voting until consensus was reached. To be approved and included as a guidance statement, the votes were required to fall into the highest third for agreement, representing moderate to high levels of consensus.
Recommendations for Managing Pediatric Rheumatic Patients
The guidance includes general recommendations, such as counseling patients and their families about public health protocols (e.g., hand washing, social distancing, wearing masks) to avoid potential exposure to SARS-CoV-2. Noting that families may be reluctant to bring their children to clinics for regular visits, Dr. Wahezi and her colleagues recommend the use of telemedicine to ensure continued access to care. The recommendations emphasize that it is equally important for physicians to continue non-rheumatic care, such as regular flu vaccinations and in-person ophthalmologic examinations if patients have a history of uveitis or are at high risk for the development of uveitis.
Dr. Mehta adds that during the first few weeks of the pandemic, he and his colleagues were worried their patients on immunosuppression would get very sick and require hospitalization. Although that has not happened, treatment decisions must be individualized for each patient and family, he says, noting “there’s a balance between keeping them safe and keeping them mentally healthy.” The guidance reminds providers that children and caregivers of children with pediatric rheumatic disease could be at risk of anxiety and depression due to the quarantine and other events surrounding COVID-19. Assessments for these risks should be conducted during regular visits.
Ongoing Treatment
The document also addresses ongoing treatment recommendations. For pediatric patients with rheumatic disease and who have not been exposed to or infected with SARS-CoV-2, regular medication regimens should be continued, or new ones initiated, to control underlying disease. For those with stable disease and who might be on stable doses of biologic or traditional synthetic disease-modifying anti-rheumatic drugs, extending laboratory testing intervals to assess for medication toxicity can be considered to reduce the risk of exposure to COVID-19.
For pediatric patients who have close or household exposure to COVID-19, the task force had generally high levels of consensus regarding glucocorticoids. Initiation of high-dose oral or intravenous (IV) glucocorticoids should be delayed by one to two weeks, if safe, only for those patients whose rheumatic disease is non-life or organ threatening. With life- or organ-threatening manifestations, high-dose oral or IV glucocorticoids should not be delayed. Finally, the guidance stipulates specific treatment options for patients with asymptomatic or confirmed symptomatic COVID-19 infection.
In The Bronx, Dr. Wahezi and her colleagues noted high levels of anxiety among families and providers. Nevertheless, many pediatric patients with rheumatic disease were not adversely affected by the pandemic. She sees addressing the fear and anxiety surrounding the pandemic as one of the main goals for the clinical guidance. In writing the guidance, she says, “We really wanted to drive home the message that controlling patients’ underlying disease is the most important goal, both to prevent long-term consequences related to their rheumatic disease and for reducing chances of infection.”
Gretchen Henkel is a health and medical journalist based in California.
