ACR Releases COVID-19 & MIS-C Clinical Guidance for Kids with Rheumatic Disease

The ACR has released clinical guidance documents for pediatric patients with rheumatic disease in the context of the COVID-19 pandemic, including one for multi-system inflammatory syndrome in children (MIS-C). Jay Mehta, MD, MS, 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 ACR COVID-19 Pediatric Rheumatology Clinical Guidance 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 multi-system 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 multi-system inflammatory syndrome associated with SARS-CoV-2 and hyperinflammation in COVID-19.

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 were submitted to, and accepted by, Arthritis & Rheumatology. In addition, Dr. Mehta notes, the guidance documents are very much living documents and will be revisited and updated as evidence evolves.

Editor’s note: The ACR hosted a virtual town hall for the rheumatology community on Aug. 11 to review the recommendations. Dr. Mehta and David Karp, MD, PhD, ACR president elect, served as co-moderators for the discussion.

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 (CDC) and other online sources for clinical questions to address.

Those questions were proposed to task force members—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.