The past few months has witnessed countries, and increasingly the world being inundated by the onslaught of the ongoing COVID-19 crisis. Since it was first discovered by Chinese authorities in Wuhan, China as a cluster outbreak of pneumonia cases,1 COVID-19 has since spread to affect multiple countries across all continents. Given its highly infectious nature and rapid uncontrollable spread, the World Health Organization (WHO) has, on March 11, 2020, declared this COVID-19 outbreak a global pandemic.2 This subsequently resulted in massive self-imposed lockdowns, mass cancellation of community events and the implementation of social distancing measures as countries scramble to keep COVID-19 infections under control.3–5 Health care systems globally are increasingly overwhelmed by the recent surge in COVID-19 infections.6,7 Inevitably, this has had a significant impact on the provision of orthopaedic care and services. In our previous paper,8 we have described how the practice of orthopaedic surgery in Singapore has been affected by this COVID-19 outbreak. Among others, nonurgent elective surgery has been canceled, outpatient clinics have been rationalized and segregated teams setup to ensure the smooth running of key services while minimizing cross-contamination. Pediatric orthopaedics has been similarly affected, if not more so than our other subspecialty counterparts. While the general principles of care and guidelines which we have earlier described still apply, there are certain nuances and specifics in pediatric care that we, in the pediatric orthopaedic community, will do well to take note of, as we adjust our clinical practice in response to this evolving COVID-19 crisis.
While general principles of care remain the same, pediatric COVID-19 infections present a significant clinical conundrum given significant differences in their pathophysiology and presentation compared with their adult counterparts. Children are less likely to be infected and also less likely to die of COVID-19 infections compared with adults.9 Even when infected, most children report a milder course of the disease, and can remain asymptomatic.10,11 An epidemiological study from Wuhan, China reported that up to 15% of pediatric patients can remain clinically asymptomatic without radiologic features of pneumonia even with ongoing COVID-19 infection.10 This difference in disease severity between children and adults is multifactorial, and are largely attributed to both exposure and host factors. Children are less likely to travel and are hence less exposed to COVID-19 infections juxtaposed to adults. Compared with severe acute respiratory syndrome coronavirus (SARS-CoV), SARS-CoV-2 (responsible for COVID-19 infections) shares similar amino acid homology and is postulated to similarly utilize angiotensin-converting enzyme 2 as a cell receptor for infection.12,13 The binding ability of angiotensin-converting enzyme 2 in children is lower than that in adults, and this possibly explains for their milder clinical disease course.14 Antibody levels in children may also be higher compared with adults, given their higher incidence of viral respiratory infections, for example, respiratory syncytial virus particularly during the winter months.15
In addition, among infected children, younger children had more severe disease compared with older ones. In a recent study published in Pediatrics,15 10.6% of infants younger than 1 year old reported severe disease compared with 7.3% in children between 1 and 5 years old, and 4.2% in older children between 6 and 10 years old. A good understanding of these key differences in symptomology, presentation and disease course between pediatric and adult COVID-19 infections is crucial in triage and diagnosis, particularly so in health care systems without ready access to laboratory testing and where maximum surge capacity has been exceeded. These nuances have significant implications on operational considerations in the pediatric setting, which we, pediatric orthopaedic surgeons should be cognizant of when designing clinical workflows, and managing pediatric patients during this COVID-19 crisis.
The general framework of orthopaedic management during this COVID-19 crisis as we previously described remain the same.8 The 3 same overarching principles need to be adhered to—(1) clinical urgency, (2) patient and health care worker protection, and (3) conservation of health care resources. Clinical management and operational workflows should accordingly be guided by these 3 principles, and applied to the inpatient, outpatient and operating theater setting in the pediatric orthopaedic context, as we rally as a community to combat this outbreak.
Firstly, in the outpatient context, general guidelines similar to those being used for adult orthopaedic patients should be followed. These include the donning of appropriate personal protective equipment, enforcement of strict hand hygiene for both patients and health care personnel, and the deployment of dedicated contamination teams in the reviewing of patients suspected of or confirmed with COVID-19 infections. The duration between nonurgent outpatient consultations should be prolonged. Text messages can be sent to patients, as they have been done locally, to advise patients to postpone their clinic appointments if they have acute respiratory symptoms, positive travel, or contact histories. Patients requiring chronic medications have also been advised to refill their prescriptions via the home delivery of medications. In the pediatric orthopaedic context, this will include the cerebral palsy patients we commonly see who may be on antispasticity modulators, for example, baclofen and patients with rickets who require their vitamin D/calcium supplements. In patients with osteogenesis imperfecta who require cyclical pamidronate infusions, we should consider the use of longer-acting zoledronate.16 This allows for a longer time interval between infusions and therefore less hospital visits,17 reducing the exposure of children to the higher risk hospital environment. Switching to oral risedronate can also be considered for patients with milder forms of osteogenesis imperfecta.18 In addition, when reviewing patients in the emergency setting, fractures where possible, should be managed conservatively without compromising on clinical care. At this time of writing, discussions are underway for the setting up of virtual fracture clinics so that selected patients can be managed remotely without undue exposure to nosocomial infections from the higher risk hospital environment.
As mentioned earlier, symptomology and clinical presentation of COVID-19 infection in children differ significantly compared with their adult counterparts. Children are likely to have a milder course of disease and can appear asymptomatic even when infected. This has significant implications on screening guidelines in the inpatient/operative setting. Current screening guidelines for our adult orthopaedic patients at the National University Hospital, Singapore, as recommended by the Ministry of Health, mandate screening only for symptomatic patients with a recent travel or contact history in the preceding 14 days before presentation.19 With a milder or even asymptomatic course, COVID-19 infection in children may not be as clear or apparent compared with adults. This complicates pediatric care significantly for clinical and nursing teams. Clinicians should maintain heightened vigilance at all times when managing pediatric patients, and have a low threshold for screening their patients for COVID-19 infections. Operationally, as mentioned earlier as well, drawing from our previous experiences with the SARS outbreak in 2003, dedicated inpatient and outpatient teams have also been setup to minimize the risk of cross-contamination. These teams rotate on a weekly basis. Inpatient teams review inpatients, perform surgeries and provide “on-call” services, while outpatient teams are responsible for seeing patients in our specialised outpatient clinics. While such a team segregation may be feasible for larger departments with better manpower resources, we recognize that this may be logistically challenging for smaller departments with lesser numbers of staff. As experienced by our local pediatric orthopaedic colleagues at the KK Women’s and Children’s Hospital (KKWCH), this team segregation practice resulted in staff being placed on overnight duty 3 to 4 times per week. These call duties were on top of their daily inpatient and surgical caseloads. Given its unsustainability and our increasing knowledge of the patterns of spread of COVID-19 (predominantly through droplets),20 this 2-team segregation policy was subsequently abolished at KKWCH after a 3-week trial. Normal clinical duties resumed, and the strict donning of personal protective equipment and hand hygiene was enforced upon all staff. Strict physical distancing guidelines were also followed. All staff maintained a distance of at least 1 m from each other, and interactions/meetings (only when strictly necessary) were restricted to <30 minutes. It is encouraging and heartening to note that so long as standard hand hygiene and personal precautions have been taken, there has been no spread of COVID-19 infections to health care workers who have been exposed to infected patients thus far.
An additional conundrum resides in that our pediatric orthopaedic patients often have accompanying caregivers, some of whom may be on stay-home notices,21 served quarantine orders,22 or placed on leave of absence due to their recent travel or contact histories. This complicates isolation policies that have been put in place to protect the other pediatric patients and their caregivers in the wards. In this time of need where resources are stretched, it may not be prudent to isolate these families in isolation rooms, which could otherwise be used for isolating high suspect COVID-19 patients. Alternative caregiver arrangements will thus need to be sought. Failing which, the care of our pediatric patients may need to be fully entrusted to our ward nurses.
Last, surgeries have been prioritized according to clinical urgency. Our COVID-19 swabs are processed by the laboratory twice a day; and it takes on average 4 hours before the swab results are made known. In urgent cases, for example, severe open fractures/devitalized limbs where a 4-hour wait for swab results may not be tenable, surgeries proceed with the surgical team donned in full protective gear, for example, powered air-purifying respirator. Less urgent emergency cases still requiring surgery (predominantly fractures and tumors) have also been allowed to proceed. In instances where these patients concomitantly complain of respiratory symptoms, mandatory COVID-19 swabs are taken. These patients are also admitted to designated isolation wards. In view of the escalating situation, all nonurgent elective surgeries have since been canceled. Only day surgery cases, for example, simple implant removals and anterior cruciate ligament reconstructions have been allowed to continue. These patients are discharged within the same day. Such a practice allows for the conservation of hospital resources and frees up operating theater manpower and hospital beds for emergency admissions. Temporizing measures must be considered for elective patients who have had their surgeries canceled/postponed as a result of the crisis. In the pediatric orthopaedic context, these are predominantly patients in whom bony work is required, that is, osteotomies for bone lengthening, complex lower limb reconstructions, hip coverage for dysplasia, etc. Patients and their parents must be appropriately counseled on the conservative options available. Patients with neuromuscular conditions, for example, Charcot-Marie-Tooth with chronic pain requiring surgery should be managed appropriately with analgesia if needed. Limb-lengthening procedures for patients with conditions such as fibula hemimelia should be managed expectantly with orthotics like a shoe raise. These patients (and their parents) should be advised to adhere to these conservative treatment plans as much as possible to mitigate the worsening of any symptoms.
Besides clinical care, we also have additional responsibilities in education and research. Fulfilling these mandates in challenging times like these requires us to step out of our comfort zones and adopt a novel, hitherto unexplored solutions. With the suspension of traditional face-to-face meetings, this is perhaps an opportune time for us to evaluate the role of technology in delivering our workplace needs. To ensure continuity in resident education, teaching sessions have now been shifted online to video-conferencing platforms, for example, ZOOM. Residents and faculty are now able to log in remotely using their laptops/hand-held devices for morning meetings and tutorials. In the same vein, technology has also been harnessed to enhance clinical communication in this period of team segregation, especially during team handovers. With the use of proprietary secured messaging applications, in our instance TigerText, teams are able to share patient information and even upload clinical photographs to ensure proper handovers, while ensuring security and data protection.
The cancellation of elective surgeries will undeniably result in the loss of precious training opportunities for our residents. This is particularly so given the relatively high elective load seen in pediatric orthopaedics. To circumvent this, our department has shifted practical training sessions to the dissection hall instead. Cadaveric anatomical dissection has been used as an important teaching tool for surgical specialties around the world.23 It has been shown to improve surgical outcomes by helping residents identify anatomical landmarks and allowing them to practice procedures without stress in a comfortable environment.24 As an academic medical center, we are fortunate to have access to human cadavers and anatomic dissection facilities. These facilities have been utilized to deliver our training needs in this time of reduced surgical caseloads. During this downtime, anatomical demonstrations have been carried out, and residents and faculty alike were able to familiarize ourselves with complex and less commonly performed procedures such as the Ganz periacetabular osteotomy and the MacIntosh procedure. Residents were also given hands-on exposure with the various surgical approaches less commonly encountered in clinical practice, for example, the posterior approach to the knee. Emergency procedures such as lower limb fasciotomies were reemphasized with cadaveric specimens. These teaching sessions were supplemented with the viewing of instructional videos, which further reinforced and consolidated learning for our residents. Early feedback has been extremely encouraging from both faculty and residents alike.
There are significant differences pertaining to pediatric orthopaedic care which are different compared with their adult counterparts. While general principles and guidelines for adult patients can similarly be applied, special key considerations need to be given for our pediatric patients. As pediatric orthopaedic surgeons, we need to be cognizant of these nuances, so as to deliver the most effective care for our patients, while ensuring our patients’ and our safety at the same time. Smooth seas never made a skilled sailor. This challenging period is a test of our resilience, our adaptability, and our resourcefulness. Our pediatric orthopaedic community can certainly punch above its weight in responding to this crisis.
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