A year later: My reflections from the paediatric frontlines of COVID-19

Dr. Jeremy Friedman, Associate Paediatrician-in-Chief at The Hospital for Sick Children (SickKids) and Professor, Department of Paediatrics at the University of Toronto

On my 10th day of a recent 12-day stint as the paediatrician in charge of the SickKids COVID-19 unit I took a moment to reflect on some of my impressions and experiences during the pandemic from the paediatric perspective. For the majority of those two weeks, we had around five COVID-positive patients on the unit. Considering that we are the only acute care children’s hospital in Toronto, where we have had high levels of community transmission, this number is thankfully remarkably low.

A smaller piece of the pandemic puzzle, we have been extremely fortunate that children have been much less sick than adults when infected with COVID-19, resulting in considerably lower rates of hospitalization. That said, there have been enormous mental health, developmental and social consequences for kids and teens over the past year, and we likely aren’t yet able to appreciate the full impact.

It has been very reassuring that to this point all of the approximately 100 COVID-positive patients admitted as of January 2021 have recovered and been discharged home in good health. A small minority, particularly older teenagers, have on occasion required care in the Paediatric Intensive Care Unit (PICU), but for the most part children have been quick to recover. In some cases, patients requiring hospitalization for other medical or surgical reasons have incidentally tested positive for COVID-19 through routine testing without any COVID-19 symptoms. In some particularly sad cases, parents have been hospitalized with severe COVID-19 illness and their SARS-CoV2-positive children have required somewhere to stay until alternative accommodation can be arranged.

The inequity in the distribution of this illness is very clear. Children of colour and those with families comprising essential workers, with little flexibility to miss work or work from home, and living in multi-generational settings have been disproportionately impacted by COVID-19. One of the most upsetting observations over the past year on the COVID-19 unit is that in some cases a family member has literally just passed away due to COVID-19 when the child or youth is admitted to our unit.

In addition to children with COVID-19 infections, we continue to admit similar numbers of children with multisystem inflammatory syndrome (MIS-C), a condition that is seen approximately three to six weeks after the initial COVID-19 infection. In total, we have cared for 120 presumed cases thus far as of January 2021. These children usually are experiencing a severe prolonged fever for more than three days and signs and symptoms of hyperinflammation. Because of the time lag from their acute infection, many of these children are no longer infectious and usually test negative on the nasal swab although they will generally have antibodies to SARS-CoV2 present in the blood. On occasion, some of these children have also required intensive care, but fortunately all have responded very nicely to treatment and have been discharged in good health. At the same time, an interesting phenomenon is that there has been a total absence of influenza and respiratory syncytial virus (RSV) infections to this point in the winter. In my 30-year career, I have never seen a January without flu and RSV, where usually our ED and inpatient wards would be full of patients with bronchiolitis and viral pneumonia. Is this purely a result of practicing physical distancing and masking amongst our kids, as well as staying at home?

To minimize the risk of infection and maximize safety for patients, families and staff, hospitals across the province have been mandated to adjust their visitor policies. While most adults seeking care in hospitals are not permitted to be accompanied by a family member, in paediatrics we have been able to permit one family caregiver at a time. Following the same approaches as our hospital partners, we have all had to make adjustments to how we provide care and engage with families. This can be especially challenging for high-needs children with medical complexity who usually need more than one set of hands for regular care, and has been even more difficult when having conversations to disclose bad news or stressful times where family support is so beneficial. We have also had to disrupt our daily family-centred rounds, where normally the entire interdisciplinary clinical team – nurse, pharmacist, dietitian, trainees, social worker, occupational therapist and physiotherapist - would put our heads together with families to make the most thoughtful decisions and ensure clarity of the plan for the day. Now only one or two team members will pop in briefly while trying to minimize their time in the cramped hospital rooms by using cellphones, tablets and video calls --a poor substitute for face-to-face interaction.

On a very personal level, facing my own anxiety about getting sick is something I haven’t had to contemplate since the 2003 severe acute respiratory syndrome (SARS) epidemic. Being the most experienced (oldest!) attending physician on the unit has always felt like an advantage. My thinning hair and wrinkled forehead have been accompanied by a calm perspective and a deep love and appreciation for the nature of the work. This past year, however, did bring home the realization that being older also comes with some increased risk. Early in the pandemic I had a few sleepless nights wrestling with the awful prospect of getting sick and requiring admission to the ICU, ventilation or even worse. Thankfully that anxiety has passed and I sleep much better these days, although I still worry about my family members living back in South Africa, as well as here at home in Toronto. I also worry about the safety of my colleagues and trainees as we navigate the new reality of testing, isolating or caring for infected family members. That said, I am conscious of and appreciate the much more significant challenges and higher risk faced by so many of our colleagues and other frontline providers in adult care.

Despite the stress of working on a designated COVID-19 unit in the hospital, the entire staff remain remarkably upbeat. Every morning when I arrive, I see only smiling eyes, even as their faces are hidden behind masks and face shields. From the cleaning staff and unit clerks, to the nurses, resident physicians and allied health professionals, they all seem to have maintained the joyful passion of caring that drew them to their roles in the first place. There isn’t a hint of self-pity or bitterness for being thrust into this new role, and the camaraderie is still visible and present behind the PPE.

The arrival of vaccines in Canada has given us a boost of optimism and we look forward to the coming months as more and more people are immunized. In the meantime, we need everyone’s help to continue to mask up, stay home and maintain physical distancing. Most importantly, be kind to one another – especially our essential workers, on whom we have relied so much throughout this pandemic – and to yourselves, knowing that there are better times around the corner.