Preventative Care & COVID-19: Adapting Pediatric Practices Amid the Pandemic

Dr. Shu:
It's become increasingly clear amid the pandemic that COVID-19 disproportionately affects adults, while pediatric patients demonstrate a lower infection rate and PICU admission. But while we wait for a vaccine to be proven safe and effective in this population, our youngest patients remain immunologically naive and have the ability to transmit COVID-19. So how have pediatric practices shifted their day-to-day operations since the beginning of the pandemic?

Coming to you from the ReachMD studios, this is COVID-19: On The Frontlines. I'm Dr. Jennifer Shu. And joining me to discuss the impact that COVID-19 has had on pediatric care is Dr. Ramiz Kseri. A dually board-certified Internist and Pediatrician and an Assistant Professor of Clinical Sciences at Florida State University College of Medicine. Dr. Kseri, welcome to the program.

Dr. Kseri:
Thank you for having me. I appreciate it.

Dr. Shu:
To start us off, Dr. Kseri, can you explain why it is so important for us as pediatricians and all healthcare professionals listening to advocate for children to be able to safely receive a COVID-19 vaccine?

Dr. Kseri:
I think what you said earlier kind of sums it up in terms of, you know, we always interact with our children. We're carrying them, we're taking them to school, we're taking them to see family. So because they do have less symptoms, but they are exposed to quite many people, they would be the perfect candidate for vaccination because by vaccinating them, we're helping in stopping the spread of the coronavirus, which is ultimately the goal so that we can return to “what is normal.” Unfortunately right now is, outside of the COVID vaccine, I'm seeing a lot of hesitancy towards vaccines in general. So even if we get to a point where the COVID vaccine is available, I worry how much of my patients would be willing to take it.

Dr. Shu:
That's an excellent point. And the other thing that I hear a lot is that, you know, children are less likely to have severe disease, but that doesn't mean that they can't have severe disease. And there also have been some deaths in the past year of the pandemic, with more deaths from the pandemic than we typically see in a year of flu infections. So while we anxiously await the first vaccine to be approved for use in children, we're obviously still coping with the drastic changes the pandemic has set forth. So what has been the biggest hurdle on your daily practice that you've had to overcome?

Dr. Kseri:
To be honest, the coronavirus has shaken up our regular pediatrician practice, because as you know, we do a lot of well checks, we do a lot of developmental screening, and we kind of hit a year where there was a huge pause. The clinic where I work is more in a rural area. And to be quite honest, we didn't hit the ground running right away with telehealth; it took us a little bit of time for adjustment. But even when we did that, some of the conversations were still hard because you're not able to truly see the child, see them move and be able to examine them basically. So what I see right now is that I'm dealing with a lot of numerous missed appointments in terms of getting updated on vaccinations. I'm seeing a lot of developmental delay. And most concerningly, I'm seeing a lot of obesity. The BMI has kind of skyrocketed for a lot of children from, you know, six months, nine months up until now. And with a lot of the schools being virtual, when we talk about physical activity, and especially we were in colder months, there hasn't been the outlet that physical school typically provides for children. So there's a lot of, you know, regular health maintenance stuff that is getting delayed, but also globally speaking, obesity is a big, big issue.

Dr. Shu:
Yeah, so in my practice, I've definitely seen school-aged kids gain 25 pounds over the past year.

Dr. Kseri:
Mhmm.

Dr. Shu:
And you know, that might be something we could have caught if they had come in for their regularly scheduled checkup, maybe six months ago or so. And, you know, this is given the fact that most kids only gain 5 pounds per year. And now we're seeing five times that amount or even more.

Dr. Kseri:
Honestly, I’m a little bit shocked because I would say at this point in time, across the age spans, you know, if I see someone's BMI within the normal range, that's becoming more of the exception, not the rule.

Dr. Shu:
Yeah, so definitely lots of concerns there. What about mental health concerns from people not coming to non-urgent or preventive visits during the pandemic?

Dr. Kseri:
So that is a big, big deal because generally speaking, people tend to need an outlet of some sort. And specifically talking, because my practice tends to have a lot of LGBTQ plus youth, this is a big problem because not everyone is out to their loved ones or family. So sometimes coming to see me in the office and the moments in time where we have a private interview is the only time that they are able to have an outlet. And if their comfort level, for example, is not to talk to their family about their current situation, then it's navigating trying to find a counselor or someone trusted to speak to. We are fortunate in our clinic that we have a social worker who is in the office with us. So a lot of time, if there's something that needs to be delegated as soon as my visit is over, I can just hop over to her office and say like, “Hey, I have this patient, A, B, and C happening. Those are my concerns. What is the next step? Who can we connect this person with?” And it's been wonderful having the social worker because, as you know, a lot of times the schedule for us gets busy, and I'm from one patient to the next. And as much as I want to spend the time on something, I don't have the opportunity to do so. And having a social worker who's able to say like, “Okay, this patient probably should go see this person, or would benefit from that person.” That has been a great help. And we've definitely in the past, I would say a few months, because we've gone back to fully physical visits, we've been utilizing her almost every day.

Dr. Shu:
Sounds like an excellent resource to have right in your medical home.

Dr. Kseri:
She has been wonderful. And more of it is also relating to your question a little bit earlier. I do a lot of, you know, the ASQs for assessing development in young ones. And when you look at the numbers, and you see certain deficits, having her has been wonderful because she knows the community so well. And she's able to tell, “Okay, this child is this age and they go to this school, let me connect you with this person. Here is where I think they can get speech therapy. Here's where they can get physical therapy.” I can't thank her enough for what she's done for my patients in the past four to six months, especially as we're finally back to catching up with care.

Dr. Shu:
For those just tuning in, this is ReachMD, and you're listening to COVID-19: On The Frontlines. I'm Dr. Jennifer Shu, and I'm speaking with Dr. Ramiz Kseri about pediatric care during the COVID-19 pandemic.

So Dr. Kseri, we spoke a little bit earlier about your daily practice. But I want to shift gears now and get your take on what's to come. Do you think telemedicine and other virtual care are here to stay in the post pandemic era?

Dr. Kseri:
I personally think so. So last year around March, at that point in time, I was in a practice that had been doing telehealth even before Coronavirus. It was part of, you know, their new innovative way of doing medicine. And we were doing it out in rural communities where sometimes the residents would travel to the students and then they would staff with me over telehealth, that way we had bigger outreach. And one of the things I realized fairly quickly is that yes, there are things where I need to see you in person. So for example, you know, if there is a concern about your breathing, obviously, I need to listen to you to be able to figure out what the issue is. But then I found for a lot of patients that I'm seeing for more counseling or we are discussing labs, or certain things like that, the example that comes to mind is diabetes. For a diabetic patient, for example, I don't need to see them, you know, every month or every two months if I'm just able to see them, you know, once a year and perhaps the other times we can discuss their blood sugars or whatever the case, we can do that over telehealth. And the same as with pediatric patients. You know, as I mentioned, obesity is a big problem that we're having. And one of the first steps that I do is a food diary. And I go over it with the patients. So you know outside of the initial visit where we discuss everything, the follow-up visits, especially for stuff like obesity, I don't see the utility of the patient physically coming in unless we need to. A lot of this can be done through telehealth.

And we've noticed that even in the short period of time we've used telehealth, it increases compliance. Like people will show up to telehealth because they're at home, they don't have to get a ride. They don't have to get dressed. So it just makes access to care a lot easier.

Dr. Shu:
Excellent points. And you know, anytime we have a challenging situation or something with a lot of change, such as a pandemic, it would be good to take advantage of this opportunity to learn something from these challenges. So what do you see are some key lessons emerging from the pandemic, and its impact on pediatric care?

Dr. Kseri:
I think the biggest thing to learn here is taking this opportunity to be prepared for the future. We have obviously had a tough time as pediatricians in the past year. And we've already talked about it; stuff from development to immunizations to obesities, pandemics in general - hopefully, we don’t get another one anytime soon. But if history repeats itself, we're on a cycle that, you know, within that another 8, 10 years, we might get another pandemic. So it's important for us to take an opportunity and see how the world went on a pause for the past year and see how we can be smarter about this, you know, in years to come.

For example, within my own private practice, thinking of the future, and how we can better help our patient, also offering stuff like walk-through vaccination clinics, that would be a big deal for at least getting children up to date, even if we have another situation where we are disconnected. And finally finding flexibility. Being able to say like, okay, what would be a hybrid mode? What would be something that would help the patient? And then lastly, unfortunately, wearing a lot of hats, because a lot of times now, especially within the pandemic, I'm having a hard time connecting my patients to anyone really. We're talking any kind of sub specialists, any kind of services like therapies. Now things are getting pushed back multiple months. So now I'm forcing myself to educate myself on how can I best assist my patients, sometimes being a one-person show, meaning the clinician is there, but no ancillary help.

So I think in that regard is just building a lot more resilience for the future and making sure that the things that happen in the past year don't repeat in the future.

Dr. Shu:
Yeah, it's been amazing to see the adaptability and flexibility in both patients and pediatricians. So that's been awesome.

To wrap up our conversation today, do you have any final thoughts you'd like to share with our listeners?

Dr. Kseri:
I would encourage everyone, especially parents, to ask your pediatrician about vaccines, ask what's in them, ask about the risk. I've heard, especially in the midst of the COVID vaccine being developed, I've heard a lot of misinformation about vaccines we already have, vaccines have already been given to children for decades. So, the COVID vaccine hesitancy has created overall vaccination hesitancy. And I would love nothing more to sit with my patient and discuss whichever vaccine they're concerned about. But let's start this conversation. Share with your clinician, what are your concerns, and then from the clinician standpoint, be patient and explain to the patient what's going on. Because what I have seen is that the level of misinformation is overwhelming. And sometimes spreading a little bit of awareness can go a long way.

Dr. Shu:
Well, this has been a fascinating look at pediatric care amidst the COVID-19 pandemic and beyond. And I want to thank you, Dr. Kseri, for joining me today. It was great having you on the program.

Dr. Kseri:
Thank you for having me.

Dr. Shu:
I'm Dr. Jennifer Shu. To access this and other episodes in our series, visit ReachMD.com/COVID-19, where you can Be Part of the Knowledge. Thanks for listening.