Caring for Pediatric Patients During a Pandemic: Q&A with Jay Mehta, MD

Caring for pediatric patients during a pandemic requires adapting health delivery services to address the physical and psychosocial needs of children and caregivers in an environment of heightened stress. Jay Mehta, MD, chair of the ACR Pediatric Rheumatology Special Committee and attending physician in the Division of Rheumatology, Children’s Hospital of Philadelphia, spoke with The Rheumatologist about how his clinic is adapting to the COVID-19 pandemic.

Dr. Jay Mehta

Q: How is your clinic adapting to the changes brought on by COVID-19?
We pivoted very quickly to telehealth. Within a few weeks, we saw nearly 100% of our regular outpatient volume using telehealth, with a few exceptions for patients we felt needed to be seen in the clinic—potential new diagnosis or suspected flare, for example. We are able to still deliver pretty good care through telehealth, even though it’s no substitute for in-person visits. For many patients, especially those who have been doing well for a long period of time—patients on stable medications with stable disease—we are able to accomplish close to what we do in person.

Q: What barriers are you seeing with adapting to telehealth?
We’re using a telehealth application that is embedded in our electronic medical record system. Initially it worked 70% of the time; about 30% of the time, calls would drop, patients couldn’t see us or we couldn’t see them, the audio wasn’t good, or we could hear but not see patients. In cases where it doesn’t work, we have to decide whether or not to bring the patient in for a clinic visit.

Another challenge is that telehealth requires a stable wi-fi connection, and not all of our families are fortunate enough to afford high-speed internet.

A further challenge is getting kids to cooperate during exams. In the clinical setting, we can be creative in how we get kids to squat down or walk, or whatever it is we ask them to do. Over telehealth, it can be challenging. When seeing teenagers, we typically ask the parents to leave the room so we can first talk to the teenager, but over telehealth it is hard to know if the parent has actually left the room.

On the provider side, there was a learning curve. We had to learn how to do musculoskeletal assessments over telehealth. We found that pGALS, or Pediatric Gait, Arms, Legs and Spine, works pretty well. It’s a screening test that a patient can do on their own, and we can watch them via video to look for signs, such as limited movement or pain, that may indicate arthritis, for example. Other things are more difficult over telehealth, such as detecting rashes or examining the oral cavity, or impossible, such as feeling lymph nodes or the liver.

Another part of the learning curve is how to incorporate other team members, including fellows, nurses and social workers, into the telehealth exam. We had to figure out solutions where we can all be on the telehealth video or call at the same time.

Q: What are the chief concerns of your patients and their caregivers during COVID-19?
The big things are questions about how underlying diseases and the medications used to treat them may affect patients’ risk of exposure to the coronavirus and getting sick. One of the good things we’ve found is that, at least according to the current data, children with rheumatic disease on disease-modifying anti-rheumatic drug (DMARD) therapy are not getting sicker or ending up in the hospital any more frequently than other children.

The one exposure that seems to put patients at risk is if they are on higher doses of steroids, with some data suggesting worse outcomes. We just put out guidelines telling providers to reduce steroids in their patients to the lowest dose that can adequately control their disease.

Parents also are asking whether kids with rheumatic disease are at higher risk of multisystem inflammatory syndrome in children (the Kawasaki-like syndrome reported with COVID-19 in some children). What we are finding is that the kids developing this syndrome were previously well and don’t have rheumatic diseases. We just published another guideline on this.

Q: How are you helping patients and their families manage the psychosocial effect of the pandemic on their daily lives?
We try to help them think creatively about how to create some socialization and suggest getting outside for walks, sun and physical activity. In our general clinical guidance, we emphasize that pediatric rheumatologists should be aware that mental health concerns can manifest themselves during a pandemic and to be aware of this and ask about it. Don’t be afraid to ask things like, “How is your child coping?”

Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.