Pediatric patients are not the sickest group right now, or the group most in danger.
But pediatricians are worried, worried for children and families, for now and for the future. On our conference calls and Zoom meetings, everyone is worried about how stressed families are right now, about what we hear from our patients or their parents about the strain of staying home — or about the strain of parents whose work requires that they go out. About parents losing jobs, and families not having enough to eat.
Let me separate out — without trying to rank them — some of the top specific worries that come up again and again from those whose business is children and children’s health.
I have to start with what we all believe is the greatest triumph of pediatrics: the ability to protect children from the diseases that used to make them sick and even kill them. This pandemic makes us remember every day that viruses and bacteria can hurt us, that infections can spread in populations without immunity.
Dr. Sally Goza, the president of the American Academy of Pediatrics, who is a primary care private practice pediatrician in Fayetteville, Ga., remembered the devastating diseases that she used to see in infants and young children as recently as the 1980s. “For the infants, if we don’t get their meningitis vaccine to them, we could start seeing meningitis again,” she said. “All those diseases I saw when I was starting out, I don’t want them to be the end of my career as well as the beginning.”
Dr. Hans Kersten, a professor of pediatrics at Drexel and St. Christopher’s Hospital for Children in Philadelphia, wrote that though they were still seeing children under 2 at his clinic, many miss visits, and the older children are missing the vaccines that are usually given at 4 and 11 years of age.
We all know that even before the epidemic, pediatricians were working hard to convince parents of the importance of vaccinating children. Now, even though many of us are dreaming of a coronavirus vaccine, many families are frightened to come anywhere near clinics or hospitals, raising the specter of resurgent infections, from measles to whooping cough, meningitis and bacterial sepsis.
Emotional trauma, anxiety and post-traumatic stress disorder
Dr. Goza said that even 3- and 4- and 5-year-olds express anxiety about the virus. Children are living in an anxious world right now — as are we all — and living with their scared, anxious parents. Many children — like many adults — are losing people they love, or at the very least, are terrified of losing people they love. No question that parents, everywhere, are doing their best, but children are going to need a lot of help, now and in the future, to deal with their feelings and their fears.
Developmental impacts of the pandemic, and especially of social distancing
Since children grow and change, their emotional needs — and their vulnerabilities — change as well. “My biggest worry about children right now is that they miss out on so many critical connections — connections with parents that are stressed out by the demands that they face at this time, connections with extended family and with other children, all of which are so critical for their social and emotional development,” wrote Dr. Danielle Erkoboni, a general pediatrician in the policy lab at the Children’s Hospital of Philadelphia.
Dr. Marilyn Augustyn, a developmental and behavioral pediatrician at Boston Medical Center, sorted her top developmental worries by age: that toddlers “will have learned that we need to be afraid of other people, wear masks and cross to the other side of the street if we see them.” That preschoolers, who tend toward magical thinking, will think that deprivations — like padlocked playgrounds — are punishments for doing something bad.
And that middle school kids and adolescents “will have consumed astronomical volumes of online media and will forget how to disconnect.”
Vulnerable populations and economic disparities
We’ve all come to understand the ways that poverty is poisonous for children, and we’re in a pandemic that seems on course to increase poverty, and to hit hardest in poor and minority communities. Even before coronavirus, the United States had a much-too-high rate of child poverty, and families with children — especially minority families — are going to need systematic and extraordinary help afterward, or the intergenerational effects will be with us all for a long time.
Dr. Daniel Taylor, an associate professor at Drexel and St. Christopher’s Hospital for Children, wrote that his biggest worry was “post-Covid amplification of existing inequities in health care for impoverished children and children of color with no viable plan, political will or financing for recovery.”
“I worry most about the lack of social safety net for not only children but the communities they live in, which are so vital to them being able to thrive,” wrote Dr. Nathan Chomilo, a pediatrician at Park Nicollet in Minneapolis, and medical director of Minnesota’s Medicaid program. We risk, he said, another generation faced with “an opportunity gap that saps them, and us as a society, of our full potential.”
School loss and educational disparities
Having school online hasn’t been easy for any set of students, but it’s harder for the most vulnerable children, the children in poverty who were already at highest risk of school problems and attend the most poorly resourced schools — and often are living in homes with parents who are under additional pressures. Lacking internet service or devices, studying with many people in the home, having unresolved learning issues — all these make keeping up much harder. These are the children who will need systematic help to come back to where they need to be educationally — and make progress.
Families are under stress. Children are home with parents who are under stress. And the usual checks and balances are missing — even the pediatric checkups are not happening in person. “There are no on-the-ground teachers, therapists, coaches or other workers to look out for these children, and no visits for them to come in to their providers,” Dr. Kersten wrote.
Missing treatments and therapies
Dr. Goza cited a child recently diagnosed with leukemia in her practice, and another who had broken an arm, but whose parents were afraid to go to the emergency room. “Because there’s a pandemic doesn’t mean there are no other diagnoses,” she said.
Dr. Julia Chang-Lin, an attending pediatrician at Bellevue Hospital, takes care of many children with special needs, who are now receiving their physical therapy, occupational therapy and speech therapy via screens; one of her patients attempted to hug the therapist on the screen, and when she couldn’t, lost interest in participating. She said that it was difficult for kids with special needs to be missing out on working in person with a trained therapist, though she wrote, “I give the parents credit for stepping up and doing all they can to support their kids.”
Concerns about what the future brings
Everyone in this story knows how hard parents are working — and everyone knows that parents are worried as well. My colleagues who are calling their patients at home are doing their best — like teachers, like therapists, like everyone who would rather be able to meet in person — to offer guidance and advice to help families navigate through this strange and scary time. Pediatric offices are going to all kinds of lengths to give vaccines safely, setting special “non-sick” hours, reducing waiting room time, vaccinating in the parking lot or at the curbside.
Some of these worries will be hard to address until the world can safely open up a little more, but they will need to be addressed. Dr. Trude Haecker, the medical director of global patient services at Children’s Hospital of Philadelphia, asked: “As we ramp up our collective reliance on digital interactions out of necessity, what does the future hold when children have been away from their extended support group for so many months?”
In general, pediatricians seem worried that in this crisis, locked into their homes, children are in some danger of becoming invisible. Children are not essential employees or front-line heroes and they are not voters or consumers — but they are, of course, our collective future.
