Multisystem Inflammatory Syndrome in children (MISC-C) and COVID-19: What providers should know

While the majority of cases of COVID-19 in children result in no symptoms or mild symptoms, some hospitals have recently reported an increased  number of cases of children with a multisystemic inflammatory syndrome that shares many characteristics with Kawasaki disease, an inflammatory disease of childhood that can affect blood vessels. Once referred to as PIMS, this new syndrome has been named multisystem inflammatory syndrome in children, or MIS-C by the Centers for Disease Control.

While research on the apparent link between COVID-19 and MIS-C is limited, scientists around the country are working to learn more about the correlation. In this Q & A,  Dr. Negar Ashouri, pediatric infectious disease specialist at CHOC Children’s, shares information about MIS-C .

What is MISC-C?

MIS-C is a condition where different body parts – such as the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs – become inflamed. Many children with MIS-C have previously been diagnosed with COVID-19 or have been exposed to COVID-19.

Is MISC-C dangerous?

MIS-C can be serious, but most children have recovered. MIS-C, like Kawasaki disease, can be a very uncomfortable illness because it causes prolonged fever, irritation and inflammation in many tissues of the body. The main concern with MIS-C and Kawasaki disease is heart and blood vessel involvement.

Conditions that involve inflammation in the heart, such as MIS-C or Kawasaki disease, can affect the heart in different ways. They may cause the heart muscle to be irritated and inflamed, affecting the overall function of the heart.

Or, it can weaken the wall of one or more of the coronary arteries causing them to bulge or balloon out. Blood clots can form in the ballooned area and possibly block the blood flow through the coronary artery. When this happens, the heart muscle will no longer receive an adequate supply of oxygen-rich blood, and the heart muscle can be damaged.

Dr. Negar Ashouri, pediatric infectious disease specialist, CHOC Children’s

What are the symptoms of MIS-C?

Though not all children will have the same presentation, these are common symptoms:

  • A fever that won’t go away
  • Abdominal pain, diarrhea or vomiting
  • Bloodshot eyes
  • Rash or changes in skin color

Patients with the following symptoms ought to seek emergency care:

  • Trouble breathing
  • Pain or pressure in the chest that does not go away
  • New confusion
  • Inability to wake or stay awake
  • Bluish lips or face
  • Severe abdominal pain

How is MIS-C diagnosed?

In addition to exploring medical history and performing a physical exam, additional tests may include:

  • Blood tests
  • Echocardiogram 
  • Electrocardiogram
  • Chest X-ray
  • Abdominal ultrasound

How is MIS-C treated?

Kawasaki and MIS-C are best treated in the hospital by a qualified multidisciplinary group of pediatric specialists who will work to to reduce inflammation and minimize long-term heart damage. Treatment may include plasma transfusions to reduce inflammation, steroids, aspirin, antibiotics or supportive oxygen.

Is MIS-C contagious?

MIS-C is not contagious.

What are the long-term effects of MIS-C?

MIS-C is a new illness and medical professionals are actively studying it to learn more,. Children who have had serious cases of MIS-C should be followed by a multidisciplinary group of specialists who will watch oversee their care.

Learn more about the infectious disease team at CHOC Children’s.

DBT in IOP setting shown to reduce intensity, frequency of suicidal thoughts in teens

Data shows that CHOC Children’s intensive outpatient program (IOP) for high school teens is successfully intervening on suicidal behaviors in participants.

Clinicians examined self-reported data gathered from patients and their parents since the launch of CHOC’s IOP in March 2018. Participants reportedly experienced less distress after completing the program, a sentiment echoed by their parents. Further, the specific sets of behaviors treated by the IOP (e.g., suicidality, emotion dysregulation and impulsivity) demonstrated reliable improvement.

“It is incredibly rewarding that our patients and their parents are experiencing meaningful improvements from CHOC’s intensive outpatient program,” says Dr. Micaela Thordarson, the program’s lead psychologist. “This data shows that we are effectively reducing stress and high-risk behaviors in our patients, which is part of the mission we set when developing and launching the IOP.”

How CHOC’s program differs

Employing dialectical behavioral therapy (DBT), the premier treatment package for suicidal adolescents, CHOC’s IOP is held four days a week for eight weeks during after-school hours. Programming includes caregivers and a variety of experiential activities. Family sessions are held as needed and optional group programming for graduates is offered.

Phone coaching is also available to allow IOP patients access to their clinicians outside of program hours to gain coaching in moments when they really need it.

By contrast, a traditional DBT program – the most widely researched – is held over a 16-to-32 week period with one weekly individual session and one weekly skills group session that includes caregivers. A 16-to-32 week graduation program and phone coaching, follow.

“This means that the clinical service CHOC provides is delivered in one-quarter to one-eighth of the amount of time as a traditional DBT program, and at a much greater intensity,” Dr. Thordarson says. “So, despite the significantly shorter time period, we are still able to get meaningful outcomes.”

Patients served

Here’s a snapshot of the population served by CHOC’s program during the approximate two-year period:

  • The IOP served 105 patients.
  • 65 percent of patients identified as female, 27 percent identified as male, and 8 percent identified as gender nonconforming.
  • 39 percent of patients were white, 31 percent were biracial, 21 percent were Latino, and 9 percent were Asian.
  • 52 percent of patients were referred from a higher level of care, such as an inpatient psychiatric unit or a residential treatment program; 17 percent from the emergency department; 21 percent from outpatient providers or from school; and 10 percent from other sources. This is significant because it means about half of the teens who are admitted to IOP are able to be diverted from an inpatient hospitalization by accessing the IOP-level of care.
  • About 80 percent of participants graduated from the program, 11 percent discharged against clinical advice, 7 percent needed a higher level of care, 2 percent needed a lower level of care, and 1 percent required a transfer for specialty care.

Measuring progress

To measure patients’ progress over the course of their time in program, teens and their parents complete the Youth Outcomes Questionnaire 2.0 (YOQ). The YOQ is a broadband measure of emotional and behavioral functioning that includes six subscales: intrapersonal distress, somatic symptoms, interpersonal relationships, social problems, behavioral dysregulation and critical items. Higher scores indicate greater distress.

At the start of the IOP, patients on average self-reported a total distress score of 92.8. At the end of the eight weeks, patients self-reported a mean score of 70.61.

Their parents reported a baseline assessment of their children’s total distress at 83.8 on average and at the program’s conclusion, reported a mean score of 56.39.

Looking more closely at the critical items subscale – which assesses suicide, self-harming behaviors, and other high risk indicators – patients at the beginning of their program reported on average a score of 12.75, followed by a mean score of 9.41 at the conclusion of their program.

Parents reported a baseline critical items subscale score of 9.78 on average, followed by a mean score of 5.53 at the program’s conclusion.

”We were table to analyze these numbers to determine not only whether they were statistically important changes, but also whether they were clinically meaningful,” Dr. Thordarson says. “These changes represent medium-to-large effect sizes. In other words, they demonstrate moderate-to-significant changes in reported distress.”

As another means of assessing program progress, patients also completed the Life Problems Inventory (LPI), a measure of the skills deficits that are specifically targeted by DBT. Like the YOQ, higher scores indicate greater distress as well as less employment of adaptive skill use. 

At the beginning of the program, patients self-reported a total mean score of 164.26; at the end, 140.

In looking at the LPI’s subscales, each decreased across the board: on average, confusion-about-self scores dropped 5.65 points; impulsivity decreased by 4.19; emotion dysregulation decreased 8.22; and interpersonal crisis dropped 6.2. These changes also represent small-to-large effect sizes.

Next steps

Looking forward, clinicians hope to gather long-term data with several goals in mind: to further assess the effectiveness in continued suicide prevention; determine any difference in outcomes when the IOP was augmented with phone coaching; review data to determine ways to further enhance the program; and continue efforts to build a referral network for ongoing family support after program completion.

“We are so thrilled to offer a very important service to teens and families who are in crisis and need extra support,” Dr. Thordarson says. “The team at CHOC is unparalleled in its enthusiastic dedication to innovation and excellence in the care of children.”

The IOP is a component of CHOC’s landmark pediatric mental health system of care launched in spring 2015 to ensure children, adolescents and young adults with mental illness get the health care services and support they need.

Learn more about CHOC’s intensive outpatient program.

Outpatient providers interested in receiving referrals from the IOP should email iop@choc.org.

Webinar to explore roles of intelligence, innovation in pediatric aspects of COVID-19

An upcoming collaborative symposium co-hosted by the Sharon Disney Lund Medical Intelligence and Innovation Institute at CHOC Children’s (MI3), will explore how innovation and intelligence can assist pediatric healthcare in a post-COVID-19 environment.

Held May 18 from 1 to 3 p.m. PDT, the live interactive webinar will feature speakers from children’s hospitals and health systems throughout the country, including Dr. Anthony Chang, CHOC’s chief intelligence and innovation officer and medical director of MI3.

Here’s a list of speakers and their topics:

  • Srinivasan Suresh, MD, MBA, FAAP – VP, CIO, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA  — Importance of Data for AI for COVID-19
  • Dawn Wolff – Chief Strategy Officer, Children’s Mercy Hospital, Kansas City, Mo. –  Leveraging Innovation Assets in a Time of Crisis
  • Omkar Kulkarni, MPH – Chief Innovation Officer, Children’s Hospital Los Angeles – KidsX. Health – Accelerating Pediatric Digital Innovation through Collaboration
  • Leanne West – Principal Research Scientist, Georgia Tech Research Institute (GTRI), Children’s Healthcare of Atlanta Pediatric Technology Center, Atlanta, Georgia and President of ICAN, International Children’s Advisory Network   Offering the Pediatric Patient’s Perspective– Pediatric Patient Panel featuring ICAN Kids
  • Jennifer Olson SVP, System Operations & Chief Strategy Officer, Children’s Minnesota, Minneapolis, MN   Innovation: A Strategic Recovery Element of Resuming the Business of Pediatric Healthcare
  • Sherry Farrugia – COO/CSO- Children’s Healthcare of Atlanta Pediatric Technology Center –  Rapid Deployment of Innovation
  • Vasum Peiris, MD, MPH – Center for Devices and Radiological Health, Office of Strategic Partnerships and Technology Innovation, U.S. Food and Drug Administration
  • Kevin Maher, MD – Children’s Healthcare of Atlanta, Emory University – Connection between COVID-19 and Kawasaki disease.

“Pediatric Aspects of COVID-19” is co-hosted by International Society for Pediatric Innovation (iSPI) and Artificial Intelligence in Medicine.

Register for the session here.

CHOC study aims to determine COVID-19 antibodies present in Emergency department staff

A CHOC Children’s Hospital study could determine how many patient-facing clinicians and staff in its emergency department have COVID-19 fighting antibodies, easing concerns of asymptomatic carriers exposing others to the virus in an acute care setting.

Using rapid serological testing, the monthlong study will determine the prevalence of viral exposure and incidence of new exposure among staff at the Julia and George Argyros Emergency Department at CHOC Children’s Hospital.

Serological blood testing looks for antibodies developed by the body to fight infection. Antibodies indicate the likelihood of past or recent infection or exposure. While researchers are still learning about COVID-19, it is also possible those who have been exposed to the virus and recovered have produced antibodies to protect them from the infection.

“While COVID-19 antibody screening is in its infancy, CHOC Children’s is pleased to help share data and contribute to this important conversation as the world’s scientific community unites in a race toward universal testing, antiviral treatment, and the development of a vaccine in order to permit a scientifically-based return to  normalcy,” said study co-principal investigator Dr. Terence Sanger, CHOC’s vice president of research and chief scientific officer.

Dr. Terence Sanger, study co-principal investigator and CHOC’s vice president of research and chief scientific officer.

Under the study, participants will undergo rapid antibody serology testing for immunoglobin G (IgG) and immunoglobin M (IgM) against COVID-19 novel coronavirus through a simple finger prick once per shift, with results available in three minutes. Additionally, all subjects will undergo viral RNA testing on their first day of the study, as well as on any day that they show IgM positive for antibodies.

In early results, all 107 people tested so far had negative results on reverse transcriptase polymerase chain reaction (RT-PCR) tests, a COVID-19 test, and all were negative for IgGs against COVID-19. Two tested positive for IgM but their viral RNA testing was negative.

As the study progresses, up to 250 subjects are expected to enroll total, with about 100 participants being tested each day.

Secondary outcomes include determining a correlation between antibody serology and DNA testing for acute infection, test-retest reliability of serology testing, evidence for direct transmission of infection between healthcare workers, and potential for reinfection in previously infected convalescent patients. 

Antibody screening could become an additional element of  CHOC’s toolkit in protecting patients, families, physicians and staff against COVID-19. Already, the hospital conducts health screenings, requires appropriate masks and personal protective equipment and practices social distancing, in addition to stringent cleaning practices.

All combined, an additional critically important benefit of the study would be the establishment of a “safe zone” in the emergency department by reducing concerns that an asymptomatic staff member or clinician could transmit the disease to a patient seeking care, or their family, despite CHOC’s strict safety and infection prevention precautions.

Hospitals and health systems nationwide are reporting declining emergency department visits, attributed to patients delaying care out of fear of contracting COVID-19 in the facility. For example, more than half of respondents in a recent NRC Health survey have delayed healthcare for themselves or someone in their home because of the virus, and 60 percent of respondents thought there was an elevated risk when visiting their providers.

Suggesting the national trend has impacted CHOC, its current emergency department volume is about 25 percent less than typical this time of year, yet patient acuity is much higher than typical.

“Seeking prompt and expert care for children in emergent situations is critically important – especially during a pandemic,” said Dr. Theodore Heyming, medical director of CHOC’s emergency department and principal investigator of the study. “We understand how frightening COVID-19 is for parents and children alike. We are excited by the possibility that this study could further prove CHOC as a haven for worried parents, and a source of safe and expert pediatric care during this outbreak – and always.”

Dr. Theodore Heyming, medical director of CHOC’s emergency department and principal investigator of the study.

The study, expected to run through mid-May, is aided by WytCote, an Irvine-based technologies solutions company that has enabled access to testing kits from Jiangsu SuperBio Medical Inc.

“This pandemic is impacting all our communities and WytCote recognized that gaining access to such testing could play a critical role towards limiting the spread of the virus. We are pleased to be partnering with CHOC Children’s to support the testing and use of this new coronavirus antibody test,” said Frank Gomez, WytCote’s CEO/Founder.

Learn more about the CHOC Children’s Research Institute

Stress coping tips for providers during COVID-19

By Melanie Fox, PsyD and Carolyn Turek, PhD. 

Any time of uncertainty commonly leads to increased stress, and the COVID-19 pandemic is the perfect definition of uncertainty. Things are changing daily, we are learning in real time, and we cannot predict with certainty exactly what is going to happen.

What we do know with certainty though is that if providers don’t practice self-care during these tumultuous times, you cannot be as effective for patients, your team and your family.  

While it can feel impossible to engage in self-care right now, it is truly imperative as stress can easily rise to traumatic and toxic levels and this biochemical reaction can cause a range of physical and mental health problems.

Read on for some tips that can easily be worked into your day – and can make a big difference.

Common stress responses

First, it’s important to understand what happens to our bodies when we experience overwhelming stress. Humans often respond in these four characteristic ways:

  • Flight: We may feel trapped, fidgety, tense in our bodies, numb in our extremities, or experience urges to leave work or cancel patients.

  • Fight: We may feel irritable or agitated. Our jaw can tighten. We may grind our teeth. We can glare, show anger in our voice, or feel a burning sensation in our chest or stomach.
  • Freeze: We often experience a sense of dread, hoping for cancellations, difficulty making decisions, feel our heart pounding, or notice ourselves checking out.
  • Avoidance: We may feel calm and composed, but anxiety manifests through impatience, irritability, short-temper, tense muscles, changes in sleep or eating patterns, and/or increased use of substances.

Tips to help in the short term

To remove yourself from the fight/flight/freeze/avoidance response, try to focus your mind and body to the present moment. Grounding exercises can help. Here are a few exercises to try:

  1. 5-4-3-2-1: Name to yourself five things you see, four things you feel, three sounds you hear, two things you smell and one thing you taste.
  2. Box breathing: Breathe in counting to four with each inhalation and count backward from four with each exhalation. Do this 4 times.
  3. Get moving: Take a quick walk before starting your next task.

These exercises can be helpful when you notice yourself reacting from a stressed place, or when you notice patients, families or other health professionals responding to you in ways that feel unhelpful or stress-inducing.

Tips to build  wellness

While no one will ever be completely stress-proof, building wellness can strengthen our ability to withstand stress.

One way to do this is by focusing on the meaning behind our work. When things seem uncontrollable or stressful, it often helps to reflect on our values and why our work is important to us.

Practicing consistent self-care is another way to build wellness. Self-care is actually patient care. Here are a few ideas to try:

  • Take deep breaths.
  • Maintain regular meals and snacks, as possible.
  • Try to get as much sleep as is possible.
  • Engage in regular physical activity.
  • Practice mindfulness.
  • Stay connected with loved ones.
  • Reduce consumption of news and social media: Studies from previous epidemics find a link between time spent on social media and increased anxiety/stress. Try to consume news at a set time from a reliable source and then try to leave it until that time the next day.
  • Try technology: Headspace, a mindfulness app, is free until the end of 2020 for anyone with a national provider number.