Public Health News

child reaching into drawer for gun

Sociodemographic factors linked to intentional youth firearm injuries

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child reaching into drawer for gun

A new study led by researchers at Children’s National Hospital, finds that sociodemographic factors related to intent of injury by firearm may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

Firearm injuries are a leading and preventable cause of injury and death among youth – responsible for an estimated 5,000 deaths and 22,000 non-fatal injury hospital visits each year in American kids. And while hospital systems are poised to tackle this issue using a public health approach, prevention efforts and policies may be differentially effective. A new study led by researchers at Children’s National Hospital, finds that sociodemographic factors related to intent of injury by firearm may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

“We sought to explore differences by injury intent in a nationally representative sample of youth presenting to the emergency department with firearm injury,” said Shilpa Patel, M.D., M.P.H., emergency medicine physician at Children’s National Hospital. “We are hopeful that hospitals will support programs that are targeted, patient-centered and relevant to their communities to prevent firearm injury among youth.”

In one of the first comparative studies of factors and outcomes associated with intentionality of youth firearm injury in a large nationally representative sample, researchers identified more than 178,200 weighted hospital visits for firearm injuries with data collected from the Nationwide Emergency Department Sample (NEDS) from 2009 through 2016. Dr. Patel and her colleagues identified distinct risk profiles for individuals aged 21 and younger, who arrived at emergency departments with firearm injuries over an 8-year period.

Using NEDS data, researchers found that approximately one third of the injuries were categorized as unintentional, another third as assault and a small proportion as self-harm. The majority of visits were among youth age 18 to 21 years with almost 90% male, and more than 40% publicly insured. Nearly a third were admitted to the hospital and 6% died as a result of their firearm injuries. In addition, the study showed that the likelihood of unintentional injury was higher among children age 12 and younger.

Unintentional firearm injuries were also associated with rural hospital location, southern region, emergency department discharge and extremity injury. Self-harm firearm injuries were associated with older age, higher socioeconomic status, rural hospital location, transfer or death, and brain, back and spinal cord injury.

“These findings provide insight into the overlap between risk factors, outcomes and intentionality of youth firearm injury,” says Dr. Shilpa.  “For hospitals looking to implement programs to reduce youth firearm injury, distinct risk profiles identified in our study align with prior evidence to support the following: screen for firearm access and provide counseling on safe storage targeting families with younger children; screen suicidal patients for access to lethal means, especially those hospitals in rural areas; and screen for firearm access especially among children exposed to violence or at risk for assault presenting to urban hospitals.”

Other researchers who contributed to this study include members of S.A.F.E.R. (Safer through Advocacy, Firearm Education and Research) — a firearm safety advocacy group at Children’s National: Gia M. Badolato, M.P.H., Kavita Parikh, M.D., M.S.H.S., and Monika K. Goyal, M.D., M.S.C.E, all of Children’s National, and Sabah F. Iqbal, M.D., of PM Pediatrics.

 

pregnant woman getting a checkup

Children’s National awarded $4.2 million to lead maternal mental health research programs

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pregnant woman getting a checkup

Mothers and their babies often experience stress, depression and anxiety, which impacts the infant’s brain development.

Children’s National Hospital announces a $4.2 million funding award from the Patient-Centered Outcomes Research Institute (PCORI) to support maternal mental health research. The Developing Brain Institute at Children’s National will lead a new program that seeks to advance perinatal mental health and well-being while addressing racial disparities in access to resources that could boost positive health outcomes for women with few opportunities.

Mothers and their babies often experience stress, depression and anxiety, which impacts the infant’s brain development. Maternal psychological distress is more pronounced among low-income mothers — a health disparity that was exacerbated during the COVID-19 pandemic.

“The new fund will support many scientific research portfolios, including our project that will ensure pregnant women in D.C. get the care they need and deserve,” said Catherine Limperopoulos, Ph.D., director of The Developing Brain Institute at Children’s National and co-principal investigator of the project.

“I’m honored to be working alongside Dr. Limperopoulos and our partners. Collectively, our team aims to meet the needs of African American pregnant and postpartum women and their families during this important transition in their lives by providing services to address social determinants of health and prevent and treat maternal distress,” said Huynh-Nhu Le, Ph.D., the co-principal investigator of the project and professor in the Clinical Psychology program, part of the department of Psychological and Brain Sciences at George Washington University.

Cognitive-behavioral intervention, patient navigation and peer support, such tailored strategies developed in the program will provide effective mental health screening and care for 1,000 mothers living in Washington D.C. that is responsive to their cultural, social, environmental, behavioral and medical needs. The participants will access the resources either online or in-person, depending on the type of assistance that fits their lifestyle.

“I am overjoyed that PCORI has provided this essential funding, giving life to our project. The research done here will have a grand effect! Our goals are ambitious: To dissect all aspects of maternal health, beyond just mental health, literally creating a detailed timeline of events a mother can anticipate experiencing from pregnancy, at delivery and postpartum,” said Shanae Bond, one of the women whose firsthand experience giving birth in D.C. informed the study design. “With the maternal health crisis we are currently facing, it’s imperative to gain this type of insight to not only support mothers but to learn how they wish to be supported and how to best improve the care they receive – based on how it impacts, improves (or impairs) their lives,” said Bond.

The multidisciplinary group includes doctors, midwives, psychologists, advisors, community leaders and four prenatal care centers, MedStar Washington Hospital Center, Howard University, The George Washington University and Unity Health Care.

“Our initiative brings together obstetrics, pediatrics, and mental health care in an integrated care model. This collaboration brings early identification and immediate care coordination to its rightful place at the center of care,” said Loral Patchen, Ph.D., CNM, vice chair, Innovation and Community Programs at MedStar Washington Hospital Center. “The prenatal period offers an opportunity for us to support emotional healing, build coping strategies, and offer a safe space for people to prepare for the complex transitions that accompany childbearing. Offering services prior to delivery optimizes opportunity for strong parent-infant attachment and mitigates potential disruptions.”

Kristin L. Atkins, M.D., FACOG, assistant professor in the Obstetrics and Gynecology Department at Howard University College of Medicine, mentioned that Howard University is honored to partner with Children’s National Hospital. “The new program will help discover more about prenatal care interventions related to maternal mental health and how they may impact fetal and pediatric brain development,” said Dr. Atkins. “We are just discovering the impact of long-standing stress on health and well-being, and this starts in utero.”

To Jennifer Keller, M.D., MPH, FACOG, associate professor at The George Washington University School of Medicine & Health Sciences, this project is essential. “The events of the last year have had a profound impact on families in this city,” said Dr. Keller. “This project begins at a time of critical mental health needs for pregnant people in D.C.”

Siobhan Burke, M.D., director of OB/GYN at Unity Health Care, is also thrilled to be part of this partnership. “We all know underlying stressors such as financial difficulties, housing instability and systemic racism can impact health, but it’s important to find out what these things do to the developing fetus and to explore strategies to make lives better,” said Dr. Burke.

In 2020, Children’s National established The Clark Parent & Child Network funded by a $36 million investment from the A. James & Alice B. Clark Foundation. The Clark Network aims to provide families with greater access to mental health care and community resources. New projects like the D.C. mother-infant behavioral wellness program underwritten by PCORI funding will become natural extensions of this essential work.

“This project was selected for PCORI funding not only for its scientific merit and commitment to engaging patients and other stakeholders, but also for its potential to fill an important gap in our health knowledge and give people information to help them weigh the effectiveness of their care options,” said PCORI Executive Director Nakela L. Cook, M.D., M.P.H.. “We look forward to following the study’s progress and working with Children’s National Hospital to share the results.”

This $4.2 million PCORI funding has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract.

 

using a laser to cut PPE face shields for staff during covid-19

Multidisciplinary team develops innovative PPE that fits clinical needs during COVID-19

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using a laser to cut PPE face shields for staff during covid-19

Children’s National engineers and clinicians developed plexiglass shields for testing sites, comfortable face shields for clinical providers, affordable oversized breath shields for ophthalmology and 3D printed flip-up attachments to the safety goggles for nurses.

The Children’s National Hospital innovation working group shares a retrospective on their local experience in mobilizing resources to offer relief following the personal protective equipment (PPE) shortages at the beginning of COVID-19. Engineers and clinicians developed plexiglass shields for testing sites, comfortable face shields for clinical providers, affordable oversized breath shields for ophthalmology and 3D printed flip-up attachments to the safety goggles for nurses.

The study, published in the Surgical Innovation Journal, narrates a series of events that occurred at the beginning of the pandemic, where the increased demand for personal protective equipment (PPE) usage in healthcare personnel skyrocketed and led to a severe national shortage. Still, the multidisciplinary approach at Children’s National facilitated the response and preparedness to the emerging situation back in March of 2020, serving as a framework for the current and future challenges.

To meet the needs of one of the busiest pediatric emergency departments in the country, the researchers aimed to develop a plexiglass shield that was reliable, reusable and practical while staying pediatric-friendly. The prototype had advantages and disadvantages while administering a COVID-19 swab test in a tent.

The 2020 FDA Emergency Authorization Use (EUA) issued in April provided manufacturing guidelines to produce face shields. Given the federal support, innovators at Children’s National, in partnership with GCMI, designed a rigid and foam prototype. Both prototypes were measured by comfort, visibility, breathability, ability to perform the job, durability, stability, fit and easy assembly. The rigid prototype performed the highest in all metrics and it had few adjustments after various tests.

“While the FDA has become nimbler as evidenced by rapid issuance of EUA of the vaccines, regulatory concerns are still paramount,” Operfmann et al. write. “Having staff experienced with regulatory processes is important to introduce new regulated devices.”

In May 2020, there was also a production lag on the available oversized breath shields for ophthalmology slits, which cost between $35 and $40. To lift the burden, the researchers designed and produced in-house a cost-effective oversized breath shield for less than $9. They used a 40 W laser machine to cut through the thick clear cast acrylic while following the compatible measurements of commercial lamps. The team also distributed the breath shields to other Children’s National regional clinics.

Within the nursing staff, the main factor associated with abiding to PPE compliance is the usage of safety goggles before entering a room. But in time-sensitive situations like patients with severe COVID-19 symptoms, the equipment can be easily forgotten. To support busy shifts, researchers designed a 3D printable attachment valued at $5 for safety goggles, which are more comfortable to keep on, even during downtime. The efficacy of the flip-up attachment is yet to be determined in an upcoming trial.

“Hospitals have already begun augmenting their disaster preparation plans and ensuring they have adequate stockpiles of equipment for future events,” Opfermann et al. write.

Children’s National authors on the study include: Justin Opfermann, M.S., Anuradha Dayal, M.D., Alyssa Abo, M.D., M.B.A., Tyler Salvador, B.S., Kolaleh Eskandanian, Ph.D., M.B.A., P.M.P., Raven McLeese, R.N., and Kevin R. Cleary, Ph.D.

Children’s National Hospital joins unprecedented coalition to address pediatric drug shortages

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Shortages of essential medicines for children are a persistent problem plaguing hospitals across the United States.

Children’s National Hospital joins in announcing the launch of a groundbreaking Children’s Hospital Coalition: Powered by PhlowTM (CHC). This first-in-kind coalition brings together some of the top children’s hospitals across the nation, in collaboration with Phlow, to provide certainty in availability and access for key medicines necessary to sustain life and conquer disease and to address the nation’s broken essential medicines supply chain.

Shortages of essential medicines for children are a persistent problem plaguing hospitals across the United States. A 2019 survey of 330 U.S. hospitals, including 29 children’s hospitals, demonstrated that medicine shortages disproportionately and uniquely impact children’s hospitals. (Vizient, 2020) The COVID-19 pandemic has exposed further vulnerabilities in the overall U.S. hospital supply chain, particularly regarding essential injectable medications. To address this issue, the CHC is charged with a mission to deliver on the promise of ensuring a reliable supply of high-quality, affordable essential medicines to treat children.

CHC logi

“Far too often, the health care needs of children are not a priority. The coalition will draw attention to this important issue of shortages of essential medicines and more importantly, start to fix the problem,” says Kurt Newman, M.D., president and chief executive officer of Children’s National. “I know we can do better for children who require these life-saving treatments and cures, and I’m proud to join this great group of organizations in developing an innovative solution.”

The coalition is working together to further escalate this issue on the national agenda, to encourage children’s hospitals to join in this cause, and educate other hospitals on how this coalition will aid in ending shortages of essential medicines. Ultimately, the goal of the CHC is to increase the resiliency and reliability of the pediatric pharmaceutical supply chain.

“The pharmacists on my team are on the front lines of this struggle every day, so we know the need for this effort all too well,” says Eric Balmir, M.S., PharmaD, C.I.M., vice president and chief pharmacy officer at Children’s National. “We’re proud to be part of the solution, working to ensure that every child has access to the essential medicines they need.”

The CHC will identify and prioritize the most needed essential medicines, including sterile injectable medicines and medications used to treat pediatric cancers and rare diseases. Phlow will work quickly to ensure a high-quality, reliable supply of these essential medicines and will provide transparent, cost-plus pricing for all coalition members under uniform long-term purchasing agreements. Through this collaboration, the CHC will work toward improving the delivery of pediatric care.

Currently, the 11 founding hospital members of the CHC are: Arkansas Children’s, Boston Children’s Hospital, Children’s Hospital Los Angeles, Children’s Hospital of Richmond at VCU, Children’s National Hospital, Children’s Wisconsin, Cincinnati Children’s, Cook Children’s, Intermountain Primary Children’s Hospital, Ann & Robert H. Lurie Children’s Hospital of Chicago and Nationwide Children’s Hospital. Please visit www.childrenshospitalcoalition.org for more information on how to join the CHC.

coronavirus

An analysis of articles on pediatric COVID-19 cases

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coronavirus

In a recent editorial, Dr. Briony Varda commented on a systematic review and meta-analysis of articles reporting on pediatric cases of COVID-19.

In a recent editorial, Children’s National Hospital Pediatric Urologist Briony Varda, M.D., M.P.H., and Emilie K. Johnson, M.D., M.P.H., from Ann & Robert H. Lurie Children’s Hospital of Chicago, comment on a systematic review and meta-analysis of articles reporting on pediatric cases of coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.

Their take home messages were that although COVID-19 is typically milder in children than in adults, children (particularly infants) do appear to have cardiac damage from COVID-19 which may be a consideration for preoperative evaluation among surgeons. They also note the MIS-C is another emerging concern for children following an infection with COVID-19.

Read the full editorial in the Journal of Pediatric Urology.

illustration of lungs with coronavirus inside

Pediatric asthma exacerbations during the COVID-19 pandemic

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illustration of lungs with coronavirus inside

The authors found that in 2020, the District of Columbia did not experience the typical “September asthma epidemic” of exacerbations seen in past years.

In the United States, pediatric asthma exacerbations typically peak in the fall due to seasonal factors such as increased spread of common respiratory viruses, increased exposure to indoor aeroallergens, changing outdoor aeroallergen exposures and colder weather. In early 2020, measures enacted to reduce spread of the coronavirus (COVID-19) — such as social distancing, quarantines and school closures — also reduced pediatric respiratory illnesses and asthma morbidity. Children’s National Hospital immunologist and allergist William J. Sheehan, M.D., and colleagues sought to determine if these measures also affected the 2020 fall seasonal asthma exacerbation peak in Washington, D.C.

The authors found that in 2020, the District of Columbia did not experience the typical “September asthma epidemic” of exacerbations seen in past years. Emergency department visits, hospitalizations and intensive care unit admissions for asthma during the 2020 fall season were significantly reduced compared to previous years.

The authors conclude that, “this is likely due to social distancing, quarantines and school closures enacted during the pandemic. This is a small silver lining in a very difficult year. As 2021 brings optimism for gradual improvements of the pandemic, careful monitoring is necessary to recognize and prepare for childhood asthma morbidity to return to pre-pandemic levels.”

Additional study authors include: Shilpa J. Patel, M.D., M.P.H., Rachel H.F. Margolis, Ph.D., Eduardo R. Fox, M.D., Deborah Q. Shelef, M.P.H., Nikita Kachroo, B.S., Dinesh Pillai, M.D. and Stephen J. Teach, M.D., M.P.H.

Read the full study in the Journal of Allergy and Clinical Immunology: In Practice.

Asthma-Related Healthcare Utilization by Month

Asthma-Related Healthcare Utilization by Month (2016-2020). Asthma-related emergency department (ED) visits, hospitalizations and pediatric intensive care unit (PICU) admissions over time by month between 2016 and 2020. The p-values are for comparisons of mean monthly numbers for fall seasons of 2016-2019 to fall season of 2020. Image courtesy of the Journal of Allergy and Clinical Immunology: In Practice.

coronavirus molecules with DNA

Novel SARS-CoV-2 spike variant found in a newborn in Washington, D.C.

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coronavirus molecules with DNA

Researchers at Children’s National Hospital found a new SARS-CoV-2 spike variant in a neonatal patient, according to a study that genetically sequenced the virus in 27 pediatric patients. The newborn presented with a viral load of 50,000 times more particles than the average patient, which led to identifying the N679S spike protein variant — the earliest known sample of this coronavirus lineage in the U.S. mid-Atlantic region.

While the paper is posted to the preprint server medRxiv and has not been peer-reviewed, it represents an early step towards establishing better surveillance of the COVID-19 pandemic. The new variant helps understand the process of viral adaptation, potentially informing treatment development and vaccine design for any viral variants in the future.

All genomes change and evolve. Additional viral variants are expected to emerge as more patients are infected. The data analysis recognized eight other cases in Washington, D.C., with the N679S variant, pointing toward a European origin due to the genetic similarity between of SARS-CoV-2 strains in the U.S. and United Kingdom.

“We need to sequence more cases to identify variants and stay ahead of the virus,” said Drew Michael, Ph.D., molecular geneticist at Children’s National and senior author of the study. “The United States sequences a tiny fraction of all cases, and because we are not sequencing enough, we are not aware of the variants in SARS-CoV-2 that may be spreading in our community.”

“Novel SARS-CoV-2 spike variant identified through viral genome sequencing of the pediatric Washington D.C. COVID-19 outbreak,” was published on the preprint server medRxiv. Additional authors include Jonathan LoTempio, Erik Billings, Kyah Draper, Christal Ralph, Mahdi Moshgriz, Nhat Duong, Jennifer Dien Bard, Xiaowu Gai, David Wessel, M.D., Roberta L. DeBiasi, M.D., M.S., Joseph M. Campos, Ph.D., Eric Vilain, M.D., Ph.D. and Meghan Delaney, D.O., M.P.H.

You can read the full preprint on medRxiv.

Nurse comforting patient

End-of-life-care goals for adults living with HIV

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Nurse comforting patient

Palliative care is specialized medical care for people living with a serious illness with the goal of improving quality of life. HIV is one illness where studies have shown that palliative care for persons living with HIV (PLWH) can improve pain and symptom control as well as psychological well-being.

There are about 1.2 million people living with human immunodeficiency virus (HIV) in the U.S., according to the CDC. In 2018, more than 37,000 people were newly diagnosed.

Integrating culturally sensitive palliative care services as a component of the HIV care continuum may improve health equity and person-centered care.

In a recent article published in the American Journal of Hospice and Palliative Medicine, Maureen Lyon, Ph.D., clinical health psychologist at Children’s National Hospital, and her colleagues examined factors influencing end-of-life care preferences among PLWH. Researchers conducted a survey of 223 adults living with HIV from five hospital-based clinics in Washington, DC. Participants completed an end-of-life care survey at as part of the FACE™-HIV Advance Care Planning clinical trial. Two distinct groups of patients were identified with respect to end-of-life care preferences: (1) a Relational class (75%) who prioritized family and friends, comfort from church services and comfort from persons at the end-of-life; and (2) a Transactional/Self-Determination class (25%) who prioritized honest answers from their doctors and advance care plans over relationships. African Americans had three times the odds of being in the Relational class versus the Transactional/Self-determination class, Odds ratio=3.30 (95% CI, 1.09, 10.03), p=0.035.

Those who prioritized relationships if dying were significantly more likely to be females and African Americans; while those who prioritized self-determination over relationships were significantly more likely to be males and non-African Americans. The four transgendered participants prioritized relationships.

Survey results show that most PLWH receiving care in Washington, D.C., preferred to die at home, regardless of race. Yet in the United States, most persons who die of HIV related causes die in the hospital. Sexual minorities feared dying alone, consistent with the stigma and discrimination which places many at risk of social isolation. Non-heterosexuals were less likely to find the church as a source of comfort, which may reflect feelings of discrimination, due to homophobic messages. However, if the church community is affirming of sexual minority status, religion could serve as a protective factor. Study findings may generate interventions to decrease social isolation and increase palliative care services for non-heterosexual PLWH.

These results fill a gap in our understanding of the self-reported goals and values of adults living with HIV with respect to end-of-life care. Findings contribute specificity to previous research about the importance of family, relationships and religiousness/spirituality with respect to end-of-life issues for ethnic and racial minorities.

Researchers from Children’s National involved in this study include Maureen Lyon, Ph.D., Jichuan Wang, Ph.D. and Lawrence D’Angelo, M.D., M.P.H.

The full study can be found in the American Journal of Hospice & Palliative Medicine.

boy checking his blood glucose

There’s still more to learn about COVID-19 and diabetes

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boy checking his blood glucose

Researchers have learned a lot about COVID-19 over the past year and are continuing to learn and study more about this infection caused by the SARS-CoV-2 virus. There have been many questions about whether COVID-19 affects people with diabetes differently than those without and why this might occur.

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population. Dr. Marks tells us more about what we know so far and further research that needs to be done when it comes to COVID-19 and diabetes.

1.      What do we know about COVID-19 and its effect on people with known diabetes?

The Centers for Disease Control and Prevention (CDC) currently lists type 2 diabetes (T2D) as a high risk condition for severe illness related to COVID-19 infection, while stating that adults with type 1 diabetes (T1D) might be at increased risk. A recent study from Vanderbilt University found that people with T1D and T2D were at approximately equal risk for complications of COVID-19 infection. As compared to adults without diabetes, adults with T1D and T2D were 3-4 times more likely to be hospitalized and to have greater illness severity. Given these comparable risks, both the American Diabetes Association and the Juvenile Diabetes Research Foundation are lobbying for adults with T1D to be given the same level or priority for COVID-19 vaccines as adults with T2D.

However, as pediatricians, we all know to be wary of extrapolating adult data to pediatrics. Children are less likely to be infected with COVID-19 and if they are, the clinical course is typically mild. To date, there have not been any studies of the impact of COVID-19 on youth with known T2D. Our clinical experience at Children’s National Hospital and reports from international multicenter studies indicate that youth with T1D are not at increased risk for hospitalization from COVID-19 infection. However, paralleling ongoing disparities in T1D care, African Americans with known T1D and COVID-19 infection were more likely to be develop diabetic ketoacidosis (DKA) than their White counterparts.

With the increased use of diabetes technologies, including continuous glucose monitors, insulin pumps and automated insulin delivery systems, diabetes care lends itself well to telemedicine. Studies from Italy during the period of lockdown showed better glycemic control among youth with T1D. Further studies are needed to better understand the implications of telehealth on diabetes care, particularly among those in rural areas with limited access to care.

Brynn Marks

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population.

2.      What do we know about the impact of the COVID-19 pandemic on children with newly diagnosed diabetes?

Nationwide studies from Italy and Germany over the first few months of the pandemic found no increase in the incidence of pediatric T1D during the COVID-19 pandemic as compared to the year before; in fact, the Italian study found that fewer children were diagnosed with T1D during the pandemic. However, many centers are seeing higher rates of DKA and more severe DKA at diagnosis during the pandemic, possibly due to decreased primary care visits and/or fears of contracting COVID-19 while seeking care.

To date, no studies have been published exploring the incidence of T2D in youth. A group from Children’s National, including myself, Myrto Flokas, M.D., Abby Meyers, M.D., and Elizabeth Estrada, M.D., from the Division of Endocrinology and Randi Streisand, Ph.D., C.D.C.E.S. and Maureen Monaghan, Ph.D., C.D.C.E.S., from the Department of Psychology and Behavioral Health, are gathering data to compare the incidence of T1D and T2D during the pandemic as compared to the year before.

3.      Can COVID-19 cause diabetes to develop?

This has been area of great interest, but the jury is still out. The SARS-CoV-2 virus, which causes COVID-19 infection, binds the angiotensin-converting enzyme 2 (ACE2) receptor which is located in many tissues throughout the body, including the pancreas. SARS-CoV-2 has been shown to infect pancreatic tissue leading to impaired glucose stimulated insulin secretion. Although the SARS-CoV-2 virus could plausibly cause diabetes, assessment has been complicated by many confounders that could be contributing to hyperglycemia in addition to or rather than the virus itself. Stress-induced hyperglycemia from acute illness, the use of high dose steroids to treat COVID-19 infection, and the disproportionate rates of infection among those already at high risk for T2D, as well as weight gain due to changes in day-to-day life as a result of social distancing precautions are all likely contributing factors.

patient talking to doctor

Advance care planning and the trajectory of end-of-life treatment preference

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patient talking to doctor

Advance care planning is a process that helps patients define their goals, values and preferences for future medical care. This information is shared with a surrogate decision maker who will make decisions for the patient if/when they are unable to make decisions for themselves. While ongoing conversations with the surrogate about goals of care are recommended, the optimal timing has not been empirically determined, until now.

Maureen Lyon, Ph.D., and her colleagues at Children’s National Hospital found that adults living with HIV and their chosen surrogate decision makers, who participated in a FAmily CEntered (FACE) advance care planning intervention, had seven times the odds of being on the same page about end of life decisions compared with controls. The researchers’ 5-year randomized clinical trial conducted in Washington, D.C., highlights a critical period 3 months after the intervention which might be optimal to schedule a booster session. FACE advance care planning had a significant effect on both surrogates’ longitudinal preparedness and confidence in decision-making and understanding of the patients’ end of life treatment preferences, compared to controls. These findings confirm advance care planning is beneficial and support African Americans’ desire to have family participate in decision making.

Children’s National researchers who contributed to this study include Maureen Lyon, Ph.D., Lawrence D’Angelo, M.D., MPH, Jichuan Wang, Ph.D., and Isabella Greenberg, MPH.

Read the full study in the American Journal of Hospice and Palliative Care.

happy children running with kite

Spurring innovation to support pediatric preparedness

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happy children running with kite

There are many lessons to be learned from the response to the COVID-19 pandemic, but one that is at the forefront is to be prepared for anything and to strengthen readiness even in the unlikeliest circumstances.

This was the focus of a recent panel discussion featuring Lee Beers, M.D., F.A.A.P, medical director of Community Health and Advocacy within the Goldberg Center for Community Pediatric Health and Child Health Advocacy Institute at Children’s National Hospital. Dr. Beers is also president of the American Academy of Pediatrics.

The webinar entitled, “Protecting Our Future: Spurring Innovation to Support Pediatric Preparedness,” was hosted by Johnson & Johnson Innovation – JLABS (JLABS) as a product of BLUE KNIGHT™, a collaboration between JLABS and the Biomedical Advanced Research and Development Authority (BARDA), a component of the Office of the Assistant Secretary for Preparedness and Response within the U.S. Department of Health and Human Services.

This event focused on what innovators can do to develop therapeutics, diagnostics, vaccines and other technologies that may protect our future, our children. Experts shared what has been done to develop groundbreaking medical countermeasures that aim to prepare and protect pediatric populations from the health threats of today and those of tomorrow. The main discussions were on ecosystems readiness, adaptations for the pediatric population and the way forward in 2021.

“One size does not fit all for pediatrics when it comes to treatments and personal protective equipment,” said Dr. Beers “We need to know the need and how to do the roll-out.” Fellow panelists agreed.

Dr. Beers went on to say that mental health is the pandemic within the pandemic for our nation’s youth. There are increased cases and severity now for children who struggle to cope with the lockdowns. “We cannot have our children bear the burdens of our challenges.”

After robust questions and answers from everything from the role of artificial intelligence in preparing for future pandemics to the inclusion of families in research and decisions, the panelists walked away with a good feeling about the future with the unprecedented speed of vaccines aimed to counter the effects of the 2020 virus crisis.

The consensus priorities of 2021 should be to develop specifics for children and not just adaptations from adults, with the aim to advance equity, diversity and inclusion in treatment goals, and to build on the success of telemedicine.

Nationally, funding for pediatric research continues to trail efforts targeted for adults. That’s why Children’s National is creating a one-of-a-kind pediatric research and innovation hub. The Children’s National Research & Innovation Campus is set to open in 2021, located on a nearly 12-acre portion of the former Walter Reed Army Medical Center campus. The campus will combine the strengths of Children’s National with those of public and private partners who share the vision of accelerating new discoveries that save and improve the lives of children. At the new campus, breakthrough innovations can more quickly be translated into new treatments and technologies benefitting kids.

Sally Allain, Head of Johnson & Johnson Innovation – JLABS @ Washington, D.C., highlighted the opening of a 32,000 square-foot facility on the Research & Innovation Campus with a residency capacity for up to 50 companies. This will be the first JLABS site anchored with a children’s hospital and research institute working to bring recognition to the need for more early-stage research and innovation in pediatrics for our smallest patients.

The new site will serve as an incubator for pharmaceutical, medical device, consumer and health technology companies, and serve as the hub for BLUE KNIGHT™. BLUE KNIGHT™ aims to stimulate innovation and incubation of technologies that improve health security and response through companies focused on public health threats and emerging infectious diseases. At JLABS @ Washington, DC, companies selected for BLUE KNIGHT™ will have access to the JLABS ecosystem and being a part of the Research & Innovation Campus, as well as fee assistance for certain costs associated with access, mentorship for BARDA, and dedicated equipment for BLUE KNIGHT™ companies.

Lee Beers

Lee Beers, M.D., F.A.A.P, begins term as AAP president

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Lee Beers

“The past year has been a stark reminder about the importance of partnership and working together toward common goals,” says Dr. Beers. “I am humbled and honored to be taking on this role at such a pivotal moment for the future health and safety of not only children, but the community at large.”

Lee Savio Beers, M.D., F.A.A.P., medical director of Community Health and Advocacy at the Child Health Advocacy Institute (CHAI) at Children’s National Hospital, has begun her term as president of the American Academy of Pediatrics (AAP). The AAP is an organization of 67,000 pediatricians committed to the optimal physical, mental and social health and well-being for all children – from infancy to adulthood.

“The past year has been a stark reminder about the importance of partnership and working together toward common goals,” says Dr. Beers. “I am humbled and honored to be taking on this role at such a pivotal moment for the future health and safety of not only children, but the community at large.”

Dr. Beers has pledged to continue AAP’s advocacy and public policy efforts and to further enhance membership diversity and inclusion. Among her signature issues:

  • Partnering with patients, families, communities, mental health providers and pediatricians to co-design systems to bolster children’s resiliency and to alleviate growing pediatric mental health concerns.
  • Continuing to support pediatricians during the COVID-19 pandemic with a focus on education, pediatric practice support, vaccine delivery systems and physician wellness.
  • Implementation of the AAP’s Equity Agenda and Year 1 Equity Workplan.

Dr. Beers is looking forward to continuing her work bringing together the diverse voices of pediatricians, children and families as well as other organizations to support improving the health of all children.

“Dr. Beers has devoted her career to helping children,” says Kurt Newman, M.D., president and chief executive officer of Children’s National. “She has developed a national advocacy platform for children and will be of tremendous service to children within AAP national leadership.”

Read more about Dr. Beer’s career and appointment as president of the AAP.

child receiving COVID test

COVID testing results highlight importance of understanding virus in children

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child receiving COVID test

A new study looking at the results of testing children for COVID-19 through a Children’s National Hospital community-based testing site found that one in four patients had a positive test.

A new study looking at the results of testing children for COVID-19 through a Children’s National Hospital community-based testing site found that one in four patients had a positive test. The findings, reported online Dec. 18 in The Journal of Pediatrics, reinforce that children and young adults are impacted by the virus more than originally believed, and that the continued understanding of their role in transmitting COVID-19 is essential to getting the virus under control.

Of the 1,445 patients tested at the specimen collection site for SARS-CoV-2 virus between March 21 and May 16, 2020, the median age was 8 years old, and more than 34% of positive patients were Hispanic, followed by non-Hispanic Black and non-Hispanic white. The daily positivity rate increased over the study period, from 5.4% during the first week to a peak of 47.4% in May. Children and adolescents were referred to the testing site because of risk of exposure or mild symptoms.

“We knew that community-based testing sites were key in minimizing exposure risk to other patients and health care workers, preserving PPE, centralizing specimen collection services, mitigating acute care site overcrowding and informing our community of the burden caused by this disease,” says Joelle Simpson, M.D., medical director of Emergency Preparedness at Children’s National.

Drive-through/walk-up testing sites outside of a traditional acute care setting have emerged around the world to meet the need for testing mildly ill or asymptomatic individuals. In March, Children’s National Hospital opened a drive-up/walk-up location — one of the first exclusively pediatric testing sites for the virus in the U.S. — where primary care doctors in the Washington, D.C., region could refer young patients for COVID-19 specimen collection and testing.

“At first, children were not the target of testing initiatives, but it is clear that making testing available to pediatric patients early was a very important part of the pandemic response,” says Meghan Delaney, D.O., M.P.H., chief of Pathology and Laboratory Medicine at Children’s National. “Not only can children get severe disease, they can be part of positive clusters with the adults they live with. The knowledge we have gained by testing many thousands of children over the pandemic has provided key information.”

Compared with non-Hispanic white children and after adjustments for age, sex and distance of residence from specimen collection site, minority children had a higher likelihood of infection.

“We wanted to identify the features of children tested at this site who did not require acute medical care and be able to compare demographic and clinical differences between patients who tested positive and negative for COVID-19,” says Dr. Simpson.

Patients with COVID-19 exposure and symptoms were more likely to have a positive test than patients without symptoms. This supports contact tracing for symptomatic cases and testing as an important tool in detecting and containing community spread, according to the study’s findings. Although most patients were referred because they lived with a family member with high risk for exposure or infection, this was not associated with positive test results.

“The impact of this virus is broad and affects planning for children, especially as schools and childcare centers work to reopen,” Dr. Simpson says. “In order to guide the development of measures to control the ongoing pandemic, we need better understand the transmission potential of these mildly symptomatic or well children and young adults.”

global connectedness concept illustration

Research partnerships and capacity building in the time of COVID-19

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global connectedness concept illustration

“COVID infection anywhere in the world is COVID infection everywhere in the world,” said John Nkengasong, M.Sc., Ph.D., director of the Africa Centers for Disease Control (Africa CDC), during his remarks on the importance of shared science, innovation and diplomacy. Leading experts in global health met virtually on November 13, 2020, to discuss updates in the COVID-19 crisis and lessons learned in Africa. Children’s National Hospital, along with the George Washington University (GW) Institute for Africa Studies and the CNRS-EpiDaPo Lab, sponsored the half-day conference that captured the interest of international attendees committed to examining how best to expand strong and enduring partnerships between U.S. and African scientists, health professionals and research institutes to meet global challenges.

Trust, transparency and communication were common themes of expert panelists that included Elizabeth Bukusi, Ph.D., M.P.H., Kenya Medical Research Institute; Maryam DeLoffre, Ph.D., GW Humanitarian Action Initiative; Peter Kilmarx, M.D., National Institutes of Health (NIH) Fogarty International Center; Enock Motavu, Ph.D., Makerere University in Uganda; Jennifer Troyer, Ph.D., Human Health and Heredity in Africa Program (H3Africa) at NIH; Désiré Tshala-Katumbay, M.D., Ph.D., National Institute of Biomedical Research in Kinshasa; Eric Vilain, M.D., Ph.D., Center for Genetic Medicine Research at Children’s National, with Institute for African Studies Director Jennifer Cooke, and Jonathan LoTempio Jr and D’Andre Spencer of Children’s National as moderators and co-conveners. Read more about the panelists.

The keynote speaker, Nkengasong, updated the group on the massive efforts in bending the COVID-19 disease curve on the African continent which at present has two million cases and 46,000 deaths. This is fewer than many other regions, and Nkengasong attributes this in part to health systems strengthening and capacity building that already occurred with past pandemics like Ebola. He stressed the importance of focusing on the “4 Ps” — population, pathogen, politics and policy — in fighting the pandemic, and the need to ensure that citizens trust their leaders and the public health measures they advance. New endeavors by the Africa CDC include the Pathogen Genomic Initiative, which will help inform research and responses to COVID-19 and other emergent disease threats, and the African COVID-19 Vaccine Development and Access Strategy, which aims to ensure widespread access, delivery and uptake of effective vaccines across Africa. Africa CDC is surging to hotspots as lockdowns ease or shift, and is empowering universities to invest in proactive and, which has helped with the active response success. “Rising tides raise all boats in the sea,” said Nkengasong. He went on to say that there is great power in coordination and cooperation, and science diplomacy and technology are critical to winning the novel coronavirus war.

In a panel on research partnerships, speakers Motavu, Tshala-Katumbay, and Vilain emphasized the global benefits of scientific collaborations in Africa. Africa contains more human genetic variation than any other region of the world, and capturing that diversity in global understanding of the human genome — which is still heavily skewed toward individuals of European ancestry — will be a major factor in global medical advances of the future. And research into relatively localized diseases can lead to breakthroughs in broader understanding on connections between climate variation, environment, nutrition and child health. “The simplistic, localized, nationalist, way of doing science is over,” said Tshala-Katumbay, “and there is no way to go back.” The discipline of science diplomacy will take time for people to grasp, he added, “but it will be crucial for the future generation of scientists to go back.”

A recurring conference theme was that collaboration between countries is crucial for development of better care. Kilmarx told the event participants that in 2019, the National Institutes of Health supported some 1,668 collaborations with African research institutions. Investments in capacity building have yielded impressive results, and today some of Africa’s foremost leaders in science research and public health have received NIH training and support, stating: “If you plant acorns over the decades, you have some mighty oaks.” Bukusi, once such NIH trainee, now is engaged in training a new generation of African researchers and U.S. researchers based in Africa and expanding research partnerships at the Kenya Medical Research Institute.

Troyer showed the successes of the Human Heredity and Health in Africa Initiative, a large consortium that supports a pan-continental network of laboratories that aims to determine disease susceptibility and drug responses. Finally, DeLoffre underscored the need for long-term investments and the value of building local capacities to respond to current crises and anticipate future challenges.

Overall, there was optimism that innovative coalitions are a long-term strength in fighting pandemics and promoting reciprocal learning that will last after the crisis. Science can be a neutral platform that, combined with diplomacy and technology, builds bridges between peoples.

pile of plastic bottles

The linkage between chemicals used in plastics and cardiovascular disease

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pile of plastic bottles

For people across the globe, plastics are synonymous with modern life and it’s impossible to avoid exposure to them, including clinical environments where a variety of frequently used materials, such as tubing and blood storage bags, are made from plastics.

For people across the globe, plastics are synonymous with modern life and it’s impossible to avoid exposure to them, including clinical environments where a variety of frequently used materials, such as tubing and blood storage bags, are made from plastics. Led by Nikki Posnack, Ph.D, principal investigator at The Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Hospital, a team of Children’s National researchers has been studying the potential effects of chemicals found in plastics, such as BPA and DEHP, as possible contributors to cardiovascular disease.

Along with conducting proprietary studies of the potential effects, Posnack and her team recently reviewed available scientific studies to further identify and illuminate the potential links between exposure to the synthetic additives contained in plastics and cardiovascular mortality. The article was published this month in Nature Reviews Cardiology.

In the article Posnack cites a 10-year longitudinal study with the finding that high exposure to BPA was associated with a 46-49% higher hazard ratio for cardiovascular and all-cause mortality, compared with low exposure to BPA.

“Plastics may be indispensable materials, but their ubiquity does raise concerns about the effects of our continuous exposure to plasticizer additives like di(2-ethylhexyl) phthalate (DEHP) and synthetic chemicals used to create polymers like BPA,” said Posnack. “Although disease causation can be difficult to pinpoint in population and epidemiological studies, experimental work has clearly demonstrated a direct link to plastic chemicals and cardiac dysfunction. It is clear that future collaborative endeavors are necessary to bridge the gap between experimental, epidemiological and clinical investigations to resolve the impact of plastics on cardiovascular health.”

Nikki Gillum Posnack

Nikki Posnack, Ph.D, principal investigator at The Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Hospital.

Posnack added that, given the omnipresence of plastics and their related chemicals, biomonitoring studies have reported detectable levels of DEHP and BPA in 75-90% of the population. Occupational or clinical environments can also result in elevated exposures to these dangerous chemicals. Previous epidemiological studies have reported links between elevated urinary levels of phthalate or bisphenol, common additives in plastic, and an increased risk of coronary and peripheral artery disease, chronic inflammation, myocardial infarction, angina, suppressed heart rate variability and hypertension.

Additionally, available research has shown that incomplete polymerization or degradation of BPA-based plastic products can result in unsafe human exposure to BPA. Despite these links, the article points out, both BPA and DEHP are still manufactured in high volumes and are used to produce a wide variety of consumer and commercial products.

Further exploring implications for pediatrics, a June 2020 article published by Posnack in Birth Defects Research looks at the potential effects of plastic chemicals on the cardiovascular health of fetal, infant and pediatric groups. The article highlighted experimental work that suggests plasticizer chemicals such as bisphenols and phthalates may exert negative influence on pediatric cardiovascular health. The article systematically called out areas of concern supported by research findings. Also addressing current gaps in knowledge, Posnack outlined future research endeavors that would be needed to resolve the relationship between chemical exposures and the impact on pediatric cardiovascular physiology.

In related work, Posnack and her team are expanding their work on plastics used in blood bags to also investigate the role of blood storage duration on health outcomes. A recently published first study demonstrates that “older” blood products (stored 35 or more days) directly impact cardiac electrophysiology, using experimental models. Published October 22, 2020 in the Journal of the American Heart Association, the study concludes that the cardiac effects are likely caused by biochemical alterations in the supernatant from red blood cell units that occur over time, including but not limited to, hyperkalemia (elevated potassium levels).

Research & Innovation Campus

Boeing gives $5 million to support Research & Innovation Campus

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Research & Innovation Campus

Children’s National Hospital announced a $5 million gift from The Boeing Company that will help drive lifesaving pediatric discoveries at the new Children’s National Research & Innovation Campus.

Children’s National Hospital announced a $5 million gift from The Boeing Company that will help drive lifesaving pediatric discoveries at the new Children’s National Research & Innovation Campus. The campus, now under construction, is being developed on nearly 12 acres of the former Walter Reed Army Medical Center. Children’s National will name the main auditorium in recognition of Boeing’s generosity.

“We are deeply grateful to Boeing for their support and commitment to improving the health and well-being of children in our community and around the globe,” said Kurt Newman, M.D., president and CEO of Children’s National “The Boeing Auditorium will help the Children’s National Research & Innovation campus become the destination for discussion about how to best address the next big healthcare challenges facing children and families.”

The one-of-a-kind pediatric hub will bring together public and private partners for unprecedented collaborations. It will accelerate the translation of breakthroughs into new treatments and technologies to benefit kids everywhere.

“Children’s National Hospital’s enduring mission of positively impacting the lives of our youngest community members is especially important today,” said Boeing President and CEO David Calhoun. “We’re honored to join other national and community partners to advance this work through the establishment of their Research & Innovation Campus.”

Children’s National Research & Innovation Campus partners currently include Johnson & Johnson Innovation – JLABS, Virginia Tech, the National Institutes of Health (NIH), Food & Drug Administration (FDA), U.S. Biomedical Advanced Research and Development Authority (BARDA), Cerner, Amazon Web Services, Microsoft, National Organization of Rare Diseases (NORD) and local government.

The 3,200 square-foot Boeing Auditorium will be the focal point of the state-of-the-art conference center on campus. Nationally renowned experts will convene with scientists, medical leaders and diplomats from around the world to foster collaborations that spur progress and disseminate findings.

Boeing’s $5 million commitment deepens its longstanding partnership with Children’s National. The company has donated nearly $2 million to support pediatric care and research at Children’s National through Chance for Life and the hospital’s annual Children’s Ball. During the coronavirus pandemic, Boeing fabricated and donated 2,000 face shields to help keep patients and frontline care providers at Children’s National safe.

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Children’s National joins international AI COVID-19 initiative

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Children’s National Hospital is the first pediatric partner to join an international initiative led by leading technology firm NVIDIA and Massachusetts General Brigham Hospital, focused on creating solutions through machine and deep learning to benefit COVID-19 healthcare outcomes.

Children’s National Hospital is the first pediatric partner to join an international initiative led by leading technology firm NVIDIA and Massachusetts General Brigham Hospital, focused on creating solutions through machine and deep learning to benefit COVID-19 healthcare outcomes. The initiative, known as EXAM (EMR CXR AI Model) is the largest and most diverse federated learning enterprise, comprised of 20 leading hospitals from around the globe.

Marius George Linguraru, D.Phil., M.A., M.Sc., principal investigator at the Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Hospital, noted that one of the core goals of the initiative is to create a platform which brings resources together, from a variety of leading institutions, to advance the care of COVID-19 patients across the board, including children.

“Children’s National Hospital is proud to be the first pediatric partner joining the world’s leading healthcare institutions in this collaboration to advance global health,” says Linguraru. “We are currently living in a time where rapid access to this kind of global data has never been more important — we need solutions that work fast and are effective. That is not possible without this degree of collaboration and we look forward to continuing this important work with our partners to address one of the most significant healthcare challenges in our lifetime.”

A recent systematic review and meta-analysis from Children’s National Hospital became another core contribution to understanding how children are impacted by COVID-19. Led by Linguraru and accepted to be published in Pediatric Pulmonology, it offers the first comprehensive summary of the findings of various studies published thus far that describe COVID-19 lung imaging data across the pediatric population.

The review examined articles based on chest CT imaging in 1,026 pediatric patients diagnosed with COVID-19, and concluded that chest CT manifestations in those patients could potentially be used to prompt intervention across the pediatric population.

Marius George Linguraru

“Children’s National Hospital is proud to be the first pediatric partner joining the world’s leading healthcare institutions in this collaboration to advance global health,” says Marius George Linguraru, D.Phil., M.A., M.Sc.

“Until this point, pediatric COVID-19 studies have largely been restricted to case reports and small case series, which have prevented the identification of any specific pediatric lung disease patterns in COVID-19 patients,” says Linguraru. “Not only did this review help identify the common patterns in the lungs of pediatric patients presenting COVID-19 symptoms, which are distinct from the signs of other viral respiratory infections in children, it also provided insight into the differences between children and adults with COVID-19.”

Earlier this month, NVIDIA announced the EXAM initiative had – in just 20 days – developed an artificial intelligence (AI) model to determine whether a patient demonstrating COVID-19 symptoms in an emergency room would require supplemental oxygen hours – even days – after the initial exam. This data ultimately aids physicians in determining the proper level of care for patients, including potential ICU placement.

The EXAM initiative achieved a machine learning model offering precise prediction for the level of oxygen incoming patients would require.

In addition to Children’s National Hospital, other participants included Mass Gen Brigham and its affiliated hospitals in Boston; NIHR Cambridge Biomedical Research Centre; The Self-Defense Forces Central Hospital in Tokyo; National Taiwan University MeDA Lab and MAHC and Taiwan National Health Insurance Administration; Tri-Service General Hospital in Taiwan; Kyungpook National University Hospital in South Korea; Faculty of Medicine, Chulalongkorn University in Thailand; Diagnosticos da America SA in Brazil; University of California, San Francisco; VA San Diego; University of Toronto; National Institutes of Health in Bethesda, Maryland; University of Wisconsin-Madison School of Medicine and Public Health; Memorial Sloan Kettering Cancer Center in New York; and Mount Sinai Health System in New York.

coronavirus

COVID-19 Pandemic: 3rd Annual CN – NIAID Virtual Symposium

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The CN-NIAID Virtual Symposium highlighted work being done to fight the COVID-19 pandemic globally.

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sick boy in bed

Clinical features of COVID-19 versus influenza

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sick boy in bed

In a cohort retrospective study comparing clinical features of COVID-19 and seasonal flu, researchers found surprisingly little difference in the rates of hospitalization, admission to the intensive care unit and mechanical ventilator use between the two groups.

As the fall approaches, pediatric hospitals will start seeing children with seasonal influenza A and B. At the same time, COVID-19 will be co-circulating in communities with the flu and other respiratory viruses, making it more difficult to identify and prevent the novel coronavirus.

With little published data directly comparing the clinical features of children with COVID-19 to those with seasonal flu, researchers at Children’s National Hospital decided to conduct a retrospective cohort study of patients in the two groups. Their findings — published September 8 in JAMA Network Open — surprised them.

The study — detailed in the article “Comparison of Clinical Features of US Children With COVID-19 vs Seasonal Influenza A and B” — showed no statistically significant differences in the rates of hospitalization, admission to the intensive care unit and mechanical ventilator use between the two groups.

The other unexpected finding was that more patients with COVID-19 than those with seasonal influenza reported fever, cough, diarrhea or vomiting, headache, body ache or chest pain at the time of diagnosis, says Xiaoyan Song, Ph.D., M.Sc., M.B., the study’s principal investigator.

“I didn’t see this coming when I was thinking about doing the study,” says Dr. Song, director of Infection Control and Epidemiology at Children’s National since 2007 and a professor of pediatrics at the George Washington University School of Medicine and Health Sciences. “It took several rounds of thinking and combing through the data to convince myself that this was the conclusion.”

Given that much remains unknown about COVID-19, the researchers’ discovery that children with the disease present with more symptoms at the time of diagnosis is a valuable one.

“It’s a good cue from a prevention and planning perspective,” says Dr. Song. “We always emphasize early recognition and early isolation with COVID. Having a clinical picture in mind will assist clinicians as they diagnose patients with symptoms of the coronavirus.”

The study included 315 children who were diagnosed with a laboratory-confirmed COVID-19 between March 25, 2020, and May 15, 2020, and 1,402 children who were diagnosed with a laboratory-confirmed seasonal influenza between Oct. 1, 2019, and June 6, 2020, at Children’s National. Asymptomatic patients who tested positive for COVID-19 during pre-admission or pre-procedural screening were excluded from the study.

Of the 315 patients who tested positive for COVID-19, 52% were male, with a median age of 8.4 years. Of these patients, 54 (17.1 %) were hospitalized, including 18 (5.7%) who were admitted to the intensive care unit (ICU) and 10 (3.2%) who received mechanical ventilator treatment.

Among the 1,402 patients who tested positive for influenza A or B, 52% were male, with a median age of 3.9 years, and 291 (21.2%) were hospitalized, including 143 for influenza A and 148 for influenza B. Ninety-eight patients (7.0%) were admitted to the ICU, and 27 (1.9%) received mechanical ventilator support.

The study showed a slight difference in the age of children hospitalized with COVID-19 compared to those hospitalized with seasonal influenza. Patients hospitalized with COVID-19 had a median age of 9.7 years vs. those hospitalized with seasonal influenza who had a median age of 4.2 years.

In both groups, fever was the most often reported symptom at the time of diagnosis followed by cough. A greater proportion of patients hospitalized with COVID-19 than those hospitalized with seasonal influenza reported fever (76% vs. 55%), cough (48% vs. 31%), diarrhea or vomiting (26% vs. 12%), headache (11% vs. 3%), body ache/myalgia (22% vs. 7%), and chest pain (11% vs. 3%).

More patients hospitalized with COVID-19 than those with seasonal influenza reported sore throat or congestion (22% vs. 20%) and shortness of breath (30% vs. 20%), but the differences were not statistically significant.

During the study period, the researchers noticed an abrupt decline of influenza cases at Children’s National after local schools closed in mid-March and stay-at-home orders were implemented about two weeks later to combat the community spread of COVID-19. Dr. Song says the impact of school closures on the spread of COVID-19 among children is the next area of study for her research team.

“We want to assess the quantitative impact of school closures so we can determine at what point the cost of closing schools and staying at home outweighs the benefit of reducing transmission of COVID-19 and burdens on the health care system,” she says.

Dr. Song urges members of the community “first and foremost to stay calm and be strong. We’re learning new and valuable things about this virus each day, which in turn improves care. The collision of the flu and COVID-19 this fall could mean an increase in pediatric hospitalizations. That’s why it’s important to get your flu shot, because it can help take at least one respiratory virus out of circulation.”

Other researchers who contributed to this study include Meghan Delaney, D.O.; Rahul K. Shah, M.D.; Joseph M. Campos, Ph.D.; David L. Wessel, M.D.; and Roberta L. DeBiasi, M.D.

young boy and teddy bear in face masks

Study provides important insight into spread of COVID-19 in children

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young boy and teddy bear in face masks

New research suggests that children can shed SARS-CoV-2, the virus that causes COVID-19, even if they never develop symptoms or for long after symptoms have cleared. But many questions remain about the significance of the pediatric population as vectors for this sometimes deadly disease.

New research suggests that children can shed SARS-CoV-2, the virus that causes COVID-19, even if they never develop symptoms or for long after symptoms have cleared. But many questions remain about the significance of the pediatric population as vectors for this sometimes deadly disease, according to an invited commentary by Children’s National Hospital doctors that accompanies this new study published online Aug. 28, 2020 in JAMA Pediatrics. The commissioned editorial, written by Roberta L. DeBiasi, M.D., M.S., chief of the Division of Infectious Diseases, and Meghan Delaney, D.O., M.P.H., chief of the Division of Pathology and Lab Medicine, provides important insight on the role children might play in the spread of COVID-19 as communities continue to develop public health strategies to reign in this disease.

The study that sparked this commentary focused on 91 pediatric patients followed at 22 hospitals throughout South Korea. “Unlike in the American health system, those who test positive for COVID-19 in South Korea stay at the hospital until they clear their infections even if they aren’t symptomatic,” explains Dr. DeBiasi.

The patients here were identified for testing through contact tracing or developing symptoms. About 22% never developed symptoms, 20% were initially asymptomatic but developed symptoms later, and 58% were symptomatic at their initial test. Over the course of the study, the hospitals where these children stayed continued to test them every three days on average, providing a picture of how long viral shedding continues over time.

The study’s findings show that the duration of symptoms varied widely, from three days to nearly three weeks. There was also a significant spread in how long children continued to shed virus and could be potentially infectious. While the virus was detectable for an average of about two-and-a-half weeks in the entire group, a significant portion of the children — about a fifth of the asymptomatic patients and about half of the symptomatic ones — were still shedding virus at the three week mark.

Drs. DeBiasi and Delaney write in their commentary that the study makes several important points that add to the knowledge base about COVID-19 in children. One of these is the large number of asymptomatic patients — about a fifth of the group followed in this study. Another is that children, a group widely thought to develop mostly mild disease that quickly passes, can retain symptoms for weeks. A third and important point, they say, is the duration of viral shedding. Even asymptomatic children continued to shed virus for a long time after initial testing, making them potential key vectors.

However, the commentary authors say, despite these important findings, the study raises several questions. One concerns the link between testing and transmission. A qualitative “positive” or “negative” on testing platforms may not necessarily reflect infectivity, with some positives reflecting bits of genetic material that may not be able to make someone sick or negatives reflecting low levels of virus that may still be infectious.

Testing reliability may be further limited by the testers themselves, with sampling along different portions of the respiratory tract or even by different staff members leading to different laboratory results. It’s also unknown whether asymptomatic individuals are shedding different quantities of virus than those with symptoms, a drawback of the qualitative testing performed by most labs. Further, testing only for active virus instead of antibodies ignores the vast number of individuals who may have had and cleared an asymptomatic or mild infection, an important factor for understanding herd immunity.

Lastly, Drs. DeBiasi and Delaney point out, the study only tested for viral shedding from the respiratory tract even though multiple studies have detected the virus in other bodily fluids, including stool. It’s unknown what role these other sources might play in the spread of this disease.

Drs. DeBiasi and Delaney note that each of these findings and additional questions could affect public health efforts continually being developed and refined to bring COVID-19 under control in the U.S. and around the world. Children’s National has added their own research to these efforts, with ongoing studies to assess how SARS-CoV-2 infections proceed in children, including how antibodies develop both at the individual and population level.

“Each of these pieces of information that we, our collaborators and other scientists around the world are working to gather,” says Dr. DeBiasi, “is critical for developing policies that will slow the rate of viral transmission in our community.”