Don't Postpone Children's Health Care in the Pandemic

As we celebrate the rollout of the new Covid vaccines, don’t forget the standard immunizations and other steps to keep children safe.

Last May, the American Academy of Pediatrics launched a campaign named #CallYourPediatrician. There were humorous visuals, to-do lists with “call pediatrician” right above “learn 3rd grade math,” informational graphics about safe visits in the time of Covid, and adorable videos (watch the baby panda getting his checkup).

But there’s still concern out there that parents aren’t calling, that children aren’t getting looked at. And there are some pediatric concerns that just shouldn’t wait. Dr. Lee Beers, a professor of pediatrics at Children’s National Hospital who is the president-elect of the A.A.P., said that bringing up problems before they become emergencies makes the visit safer: “You can be much more planful with routine visits as opposed to urgent visits — or you may end up in the emergency room, or overnight in the hospital.”

As we celebrate the rollout of the new Covid vaccines to the adults who are most at risk, let’s remember the standard childhood immunizations that keep our children safe. We’ve been hearing since the spring that the rates of routine vaccination have been falling, with lots of babies and young children behind in their immunizations.

We call these shots “standard” and “routine” because we’ve come to take that safety for granted, but there is nothing routine about the diseases. Dr. Eileen Costello, a clinical professor of pediatrics at Boston University School of Medicine and chief of ambulatory pediatrics at Boston Medical Center, said that because of the worry about outbreaks of diseases like measles and whooping cough last spring, “We instituted a mobile vaccination program to keep our kids vaccinated.”

The influenza vaccine is even more important this year. Nobody needs another virulent respiratory virus right now, and flu can be very serious in young children. Every child 6 months and up should get vaccinated against influenza. It’s especially high priority for children with asthma or other underlying illnesses such as heart or kidney problems — who may also be at additional risk from Covid.

Everyone in medicine is worried about the possible overlap between Covid and flu, and again, getting vaccinated — calmly, routinely, safely — against influenza now means no emergency influenza trip to the doctor — or the emergency room — with a miserable, feverish child (and a terrified parent). “The healthier we all stay this winter, the better,” Dr. Beers said.

Dr. Jesse Hackell, a practicing pediatrician in Rockland County who is the chairman of the A.A.P. committee on practice and ambulatory medicine, said, “The biggest concern we have is that even though we’re consumed by the pandemic, the other stuff doesn’t go away.” He worries, he said, about parents who may be focused on Covid “ignoring other symptoms that in other times would have led to them being in touch with us.”

When children are more fatigued than usual, or complaining of stomach aches, or urinating frequently, pediatricians don’t jump immediately to diagnoses like leukemia or appendicitis or new onset diabetes — but you always keep those possibilities in mind, and you’re grateful for the chance to talk things through with parents before there’s a crisis.

Every doctor I spoke to had regretful stories about families who were too scared to come to the clinic or the emergency room. The adolescent girl with bad headaches and neurological symptoms who turned out to have a brain tumor. The little girl who had been drinking more and urinating more for a couple of months and had new onset diabetes with a dangerously high blood sugar and metabolic abnormalities.

Dr. Ellen Stevenson, a professor of pediatrics at Oregon Health and Science University, said that there had been cases where parents waited on skin infections, so they worsened to the point that children needed oral antibiotics, rather than soaks and antibiotic ointment.

“Covid has taken all the air in the rooms, but we need to remember that other diseases are still out there,” said Dr. Sally Goza, the president of the American Academy of Pediatrics, who is a primary care private practice pediatrician in Fayetteville, Ga. During the course of the pandemic, she said, she has taken care of a child who had recurrent fevers and turned out to have leukemia, and diagnosed acute appendicitis over the telephone. “There was chronic constipation, but the abdominal pain was a little different,” she said. “Luckily it had not ruptured.”

“If the recommendation is that you need to go in, you should go in; hospitals are in many ways some of the safest places to go, we’re so cautious,” Dr. Costello said.

Children with asthma, diabetes, sickle cell disease, inflammatory bowel disease, and other problems that require regular check-ins and preventive medications should be getting their care, “making sure your chronic conditions are being managed optimally,” Dr. Beers said. Some of this can happen remotely; make sure these children have their prescriptions adjusted and up-to-date, and that parents know exactly what to monitor.

Young children’s lives have been disrupted since last spring. They may not have been in the company of other children, so parents have not had the chance to make the kind of comparisons that sometimes raise developmental questions.

With many children for whom there were already questions, the pandemic interrupted the often lengthy process of evaluation and diagnosis. That means that months are passing without children getting evaluation, therapy and special help in the early years, when that help can matter most.

Dr. Stevenson worries when “I see someone who had a developmental concern who had been referred pre-pandemic and is still waiting.” Some children are getting early intervention services virtually, she said, but others are not getting help.

Health disparities touch every aspect of taking care of children, and right now those who provide health care are deeply aware that limited technology means limited access to the conveniences of telehealth and a greater chance of being missed.

The economic hardships of the pandemic mean that many families are struggling with food and housing. Dr. Stevenson said, “There are so many newly food insecure children based on parents newly unemployed.” Many families in this situation are not familiar with the benefits they might be eligible for, she said, and “I worry about nutrition and access to healthy food during those critical early years when children are establishing habits.”

In more normal times, pediatricians try to touch on mental health at checkups, and starting in early adolescence, we include a private conversation, in which we can ask about mood and emotional well-being. “Children, a lot of times, aren’t going to tell their parent when they’re depressed or anxious,” Dr. Goza said.

“Any concern about a mental health diagnosis should be addressed as a relative emergency,” Dr. Costello said, and therapy for mental health issues can be provided remotely.

Children who had already been struggling with mental health concerns may be at especially high risk right now, with the extraordinary stresses of the pandemic, but their parents may be aware, and they may already have connections to counselors and therapists. If you’re worried that a child may be struggling, and aren’t sure where to turn, start by talking it through with the child’s primary care provider.

In the end, Dr. Hackell said, “I think the kids are going to be OK.” For many kids this will be something of a “lost year,” but when they get back to going to school and being with their friends, he believes in their resilience. But that makes it even more important to identify the ones who are having a particularly tough time now, and get them help. “I’ve got a lot of faith they’re going to bounce back as long as we’re there to help them through it,” he said.

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