key: cord-310944-tfn0ltrz
authors: Peck, Jessica L.
title: COVID 19: Impacts and Implications for Pediatric Practice
date: 2020-07-09
journal: J Pediatr Health Care
DOI: 10.1016/j.pedhc.2020.07.004
sha: 
doc_id: 310944
cord_uid: tfn0ltrz

Since the rapid emergence of the novel coronavirus in December of 2019 and subsequent development of a global pandemic, clinicians around the world have struggled to understand and respond effectively and efficiently. With global response encompassing social, political, organizational, and economic realms, world leaders are struggling to keep pace with the rapid changes. Challenges within global healthcare system and the healthcare profession itself include rationing supplies and services within health care systems, many of which were stretched to the brink before this latest viral outbreak (American Hospital Association, 2020). Leaders are making policy decisions while balancing the slow and precise nature of science with the rapid and pressing need for life-saving information (Altmann, Douek, & Boyton, 2020). Shortcuts on research are occurring, including publishing papers with lack of peer review. Social media and lurid reporting bolster feelings of mistrust and panic-buying while burgeoning conspiracy theories commandeer national dialogue. This is a time in history to prioritize global health and thoughtful pandemic preparedness (Lancet, 2020). Pediatric Nurse Practitioners (PNPs) are ideally situated to be a trusted source of accurate health information for children. This continuing education article summarizes the latest evidence-based information on the rapidly developing coronavirus pandemic; equipping PNPs for clinical preparation and response. 1.. Distinguish risk factors for COVID-19-related morbidity and mortality and identify modes of transmission. 2.. Appraise appropriate COVID-19 testing parameters and procedures for children. 3.. Compare pediatric clinical presentation to adults with COVID-19 infection and recommend appropriate treatment measures. 4.. State appropriate infection-control measures to reduce transmission. 5.. Describe measures to reduce the risk of infection spread, mitigate adverse health effects in high-risk children, and to promote general health through preventive care.

media and lurid reporting bolster feelings of mistrust and panic-buying while burgeoning conspiracy theories commandeer national dialogue. This is a time in history to prioritize global health and thoughtful pandemic preparedness (Lancet, 2020) . Pediatric Nurse Practitioners (PNPs) are ideally situated to be a trusted source of accurate health information for children. This continuing education article summarizes the latest evidence-based information on the rapidly developing coronavirus pandemic; equipping PNPs for clinical preparation and response.

Severe Acute Respiratory Syndrome (SARS) family and is also referred to as SARS-CoV-2. COVID-19 is a zoonotic, enveloped, single-stranded ribonucleic acid (RNA) virus that can quickly mutate and recombine, creating novel virus strains that spread from animals to human. There are currently four strains of coronavirus circulating in humans, all thought to originate in bats.

COVID-19 was first reported in Wuhan, China; with controversial and unsubstantiated reports on the nature of its origin. Coronaviruses are known for causing severe respiratory distress and respiratory failure along with coagulopathies, multi-system organ failure, and death (Zimmerman & Curtis, 2020) .

The timeline (see Figure 1 ) of the COVID-19 outbreak is astonishing, as China first reported a cluster of cases of pneumonia in Wuhan on December 31, 2019. Just a month later the World Health Organization (WHO) declared a public health emergency of international concern and by March 11 th , assessed the crisis as a global pandemic (WHO, 2020) . Response in the United States (US) evolved rapidly as President Trump declared a state of national emergency under the Stafford Act on March 13 th . Six days later, California became the first state to issue a statewide stay-at-home order. The following week, the U.S. National Guard was activated in all fifty states. By the end of March, New York City emerged as the epicenter in the US and by the end of April, the US reported more than one million cases, the highest number in the world (Kantis, Kiernan, & Bardi, 2020) .

Declaration of a public health emergency has directed the entire healthcare system to initiate population-based triage, the management of massive numbers of individuals seeking care. Tasks in this strategy include providing crisis leadership, sustaining organizational response, and achieving disease containment. Triage-based categories include addressing susceptible, exposed, infectious, removed, and/or vaccinated populations, usually through an incident command system. Goals are divided into two phases (see Table 1 ). Phase one addresses broad generic interventions based on best public health practices, while phase two management decisions are surge-dependent and specific to the five aforementioned triage categories (Burkle, 2008) .

Children are a population who have been spared significant burden of severe illness. To date, two studies (n= 2,143 and n= 171) have described similar COVID-19 findings in pediatric patients. Boys are more commonly affected than girls and most children were either asymptomatic or mildly symptomatic. Children younger than three years of age and those with congenital heart disease seem to be disproportionately impacted (Yagnik et al., 2020) .

Social determinants of health are emerging as a predictor of health disparity in COVID-19, many of which impact pediatric populations. Essential workers are less likely to be able to work from home and financially tolerate furlough. Persons with crowded housing, inconsistent access to care, chronic conditions, and high stress levels impacting immune function are more susceptible to adverse outcomes as are those who experience racial or ethnic prejudice and/or discrimination (Golden, 2020) . People of color, particularly African Americans, experience more serious COVID-19-related morbidity and mortality. While African Americans make up 13% of the US population, they account for approximately 30% of deaths, and up to 75% of COVID-19related deaths in Chicago. Asian Americans show similar disparity at 18% of the US population and 23% of COVID-19 deaths (Golden, 2020) . Other populations at significant risk include older adults (> 65 years of age), persons with underlying medical conditions (e.g., asthma, cardiovascular disease, kidney disease), persons with immunocompromise, persons with severe obesity (body mass index >40), persons with diabetes, persons undergoing dialysis, and persons residing in long-term care or nursing homes (CDC, 2020c) . Care must be taken to ensure equitable, transparent provision of services during this pandemic.

COVID-19 is thought to spread mainly from person-to-person, primarily through close contact and droplet exposure from distances of six feet or less (Zimmerman & Curtis, 2020).

Children carry the COVID-19 virus in the upper respiratory tract, making it easier to spread in childcare centers, schools, and homes; where pediatric respiratory hygiene is inconsistent and problematic (Zimmerman & Curtis, 2020). R 0 (pronounced R-naught) is the average number of secondary cases attributable to an index case. In other words, it is the average number of persons someone with COVID-19 is predicted to infect. R 0 estimates for COVID-19 range from 2.0-5.7. Experts project 82% of the population needs immunity (antibody induced or vaccine acquired) to stop transmission and achieve herd immunity (Ramirez, 2020) . Early analysis suggests active public health surveillance, contact tracing, quarantine implementation, and coordinated social distancing efforts are critical in stopping the spread of COVID-19 (Sanche et al., 2020) .

As of June 25, 2020, there were no confirmed cases of COVID-19 intrauterine transmission, although there were concerns over possible correlation to miscarriage, intrauterine growth restriction and preterm delivery (Zimmerman & Curtis, 2020) . In the weeks following this report, however; there is growing evidence maternal-fetal transmission is occurring (Alzamora et al., 2020) . Unlike earlier outbreaks of SARS, COVID-19 yields fewer maternal mortalities (Schwartz, 2020) . COVID-19 outcomes of pregnant women are similar to women who are not pregnant, including the need for intensive care. As of May 1, seven maternal deaths have been reported (D'Ambrosio, 2020).

There is currently no evidence to suggest COVID-19 transmission is foodborne, although early reports indicate the virus can live up to 24 hours on cardboard and paper (i.e. food packaging containers) and up to three days on harder surfaces (CDC, 2020h) . Current advice to reduce transmission associated with grocery shopping or take-out food includes handwashing before and after handling food packaging, removing packaging prior to eating, limiting trips to the grocery store, and ensuring food preparers (including grocers and restaurants) are complying with health guidance such as wearing masks and screening workers for illness (CDC, 2020h) .

There are currently no reports of domestic pets as vectors, although one tiger at a New York City zoo tested positive (CDC, 2020e). If persons are ill with known or suspected COVID-19, it is wise to self-isolate from pets if possible. To lower risk of transmission, dogs should be walked on a leash, keeping a six-foot distance from other people and animals. Crowds should be avoided, and pet-owners should not allow strangers to pet their animals. If a pet shows signs of illness, the veterinarian should be called for further instruction as opposed to arriving unannounced at an animal clinic (CDC, 2020e).

Pediatric healthcare providers have always demonstrated expertise in promoting general holistic health, and now that task is more critical than ever as persons with pre-existing medical conditions are disproportionately affected by adverse outcomes from COVID-19. Table   2 offers strategies for targeted health interventions to optimize health and mitigate potential serious and life-threatening outcomes associated with COVID-19 infections.

Non-pharmaceutical interventions (NPIs) are actions, apart from immunization and medication administration, people and communities can take to help slow the spread of illness.

The goals of NPIs are to prevent and/or minimize morbidity and mortality while minimizing social disruption and economic effects. Timing is crucial to ensure NPIs are applied with the least restrictive measures which provide the greatest public health benefit (Banholzer et al., 2020) . The challenge of NPIS is that evidence of efficacy is always retrospective. Evidence concerning NPIS implemented to mitigate the spread of COVID-19 in the US is to date, inconclusive, although early analysis conducted by Banholzer et al., (2020) is promising (Table   3 ).

Social distancing (e.g. maintaining a physical distance in public at a minimum of six feet from persons not living together in the same household) has emerged as a critical NPI to slow the spread of COVID-19 (Messonier, Lipsitch, Stripling, & Markel, 2020) . Families can be equipped by healthcare providers who emphasize the importance of promoting adherence.

Role modeling from parents and other adults in the home is an effective way to encourage children to adhere to public health guidelines. Parents should emphasize personal responsibility, especially with adolescents, by establishing clear expectations and firm guidelines with instruction including ways in which lack of personal responsibility can adversely impact the lives of others. Families should also consider postponing visits to see older family members or grandparents and consider use of technology to maintain emotional and relational connections (Inouye, Schuchat, Aiello, Galea, & Nuzzo, 2020).

On April 3, 2020, the CDC made a departure from previously issued guidance with a broad recommendation for anyone over two years of age to wear face masks or coverings while in public. This does not replace recommendations for social distancing or personal hygiene measures to control the spread of COVID-19 (CDC, 2020b). Persons excluded from mask usage include babies less than two years of age, and persons who have trouble breathing, are incapacitated or are unable to remove a mask without assistance. Mask use is more effective in protecting others from spread of viral pathogens than protecting the wearer from infection.

Ideal fabrics for Do-It-Yourself masks include denim, canvas, and paper towels, with scarves as a last resort. Layering adds potential protection, but also can decrease ability to breathe easily (CDC 2020b). In general, surgical masks and N-95 respirators should be reserved for healthcare workers and other first responders. In healthcare settings, N-95 masks should be reserved for high-risk aerosolizing procedures such as intubation and endotracheal suction and high-risk healthcare workers including those with a history of asthma. The use of expired N-95 masks may be acceptable in some circumstances. Fit-testing and seal-check is recommended for all N-95 mask use, expired or not (McMillan & Rebman, 2020) . The straps and bridge of the nose are usually the first areas to break down and should be visually inspected before use. To preserve masks and maximize usage, longer usage is preferred over re-usage. A face shield used over a mask is preferred and may help extend the life of the mask (McMillan & Rebman, 2020).

Lack of adequate personal protective equipment (PPE) has been a widely publicized and broadly discussed concern of healthcare providers, first responders, and essential workers.

Ideal PPE when caring for a patient with known or suspected COVID-19 infection includes: a new N-95 mask, gown, medical grade gloves, and eye covers and/or a face shield (CDC, 2020b).

Proper donning and doffing of PPE are essential to prevent viral spread. Institutions should take care to implement protocols and training to adequately equip personnel. Hand hygiene should be performed before and after removal and masks should be removed by the straps and handled with gloves. If there is limited or no PPE in a health care setting, usage should be reserved for high-risk persons (e.g. persons > 60 years of age, with chronic medical conditions, or pregnant) or those performing high-risk aerosolizing procedures such as intubation, endotracheal suction, or cardiopulmonary resuscitation. Limiting visitors in the healthcare setting can be a measure to reduce PPE usage (McMillan et al., 2020) . The CDC has issued guidelines for reuse of surgical gloves, masks, and other PPE should new items not be available.

Homemade PPE should be used a last resort. The CDC has a PPE Burn Rate Calculator tool available online to help estimate usage and ordering needs for healthcare settings (CDC, 2020b).

Frontline personnel and essential workers are concerned about COVID-19 transmission to family members and household contacts. Self-quarantine should be considered, particularly if there are persons in the home at high-risk for adverse outcomes from COVID-19 (Little et al., 2020) . Several hotel chains are offering free lodging to frontline personnel, and many other community efforts include donation of vacation homes or recreational vehicle use. If selfisolation is not possible, a separate room and bathroom is ideal if available for symptomatic persons, with delivery of meals using disposable plates and utensils.

Frontline workers should remove all clothing and shower at their place of employment if possible. Alternatively, stripping clothing in the garage or designated entry spot of the home while placing soiled clothing in a garbage bag for laundering is preferred. Shoes should be removed and placed in a plastic bin at the home entrance. Cleaning soles of shoes with bleach is not recommended, as it may increase risk of exposure.

Frontline workers should regularly self-monitor for symptoms including temperature and promptly report any potential signs of illness (Charbonneau, 2020). Evidence is still emerging on efficacy of these efforts, but early results point to handwashing, disinfecting carefully, avoiding sharing rooms and surfaces, managing home deliveries with caution, and ensuring adequate ventilation as most efficacious. Healthcare providers can help families plan for modifications of behavior and factors in the home environment with assistance in problem solving to overcome barriers (Little et al., 2020) . In addition to consideration in the home setting, careful attention should be given to measures within the healthcare setting to minimize the risk of nosocomial infection (Table 4) .

The gold standard of diagnosis for COVID-19 remains the reverse transcriptasepolymerase chain reaction (RT-PCR) using a nasopharyngeal swab, which demonstrates greater reliability over salivary or oropharyngeal specimen analysis (Sethuraman, Jeremiah, & Ryo, 2020) . RT-PCR positivity is estimated to persist approximately three weeks beyond the onset of illness, indicating only the detection of viral RNA and not necessarily viable transmittable virus (Sethuraman, Jeremiah, & Ryo, 2020) . At the end of May 2020, the US is performing approximately 150,000 tests per day with a daily goal of 500,000. Nationally, the positive rate is around 20% while Germany is reporting 6% and South Korea 3%. Positive rates of more than 10% indicate less than ideal conditions and inadequate testing (Relman, Taylor, & Benjamin, 2020) . Currently there are approximately 70 assays commercially available with wide variability in length of testing and significant supply chain issues affecting availability of cotton swabs, reagents, and other items necessary to complete testing. As rapid point-of-care tests emerge on the market (currently there are three), they arrive with a disadvantage of threats of inconsistency in reporting, creating more challenges with contact tracing. Sensitivity and specificity currently vary widely and need further investigation (Relman et al., 2020) . In clinical cases with a high index of suspicion and an initial negative nasopharyngeal RT-PCR, repeat testing should be pursued (Zimmerman & Curtis, 2020).

Testing of children is variable by region related to state and county guidelines, testing availability and accessibility, and community prevalence. Time estimations of RT-PCR positivity and seroconversion are still unknown in children because largely adult populations have been studied to date. Some concern has emerged after reports of persistent PCR in stool specimens, suggesting possible implications for high-risk caregivers of children who need assistance with elimination needs (Sethuraman et al., 2020) .

Serology testing for COVID-19 antibodies is rapidly emerging to explore individual immunity as well as the use of convalescent plasma in therapy for persons with active infection.

The Food and Drug Administration (FDA) issued rapidly changing guidance on antibody testing, initially waiving the need to apply for an Emergency Use Authorization (EUA) but later requiring application within ten days of appearance on the commercial market. If the test does not meet FDA standards, testing must be suspended (Shah & Shuren, 2020) . Experts advocate for a thoughtful, deliberate approach to ensure the utmost standards of scientific rigor and safety to guide high-stakes policy decisions (Altmann, Douek, & Boyton, 2020) .

Barriers to testing are influenced by social determinants of health. Although the federal government passed legislation to cover cost of COVID-19 testing, cost of care associated with the diagnostic test may not be covered. Locations of testing centers should be accessible to the community and drive-through testing centers should make accommodations for those who do not have a car (Relman et al., 2020) . Testing times should provide flexibility in consideration of employment hours of essential workers. Efforts should be made to eliminate racial or ethnic discrimination while providing reassurance and anticipatory guidance to counter fear of stigma resulting from a positive test. Many primary care systems are severely impaired, and many overwhelmed emergency centers may turn patients away. There is much work to be done to ensure equitable access for all to COVID-19 related care (Relman et al., 2020) .

It appears children present with similar symptoms described in adults with active COVID-19 infection, although most are either asymptomatic or mildly symptomatic. In late April 2020, the CDC added six symptoms now believed to be associated with COVID-19 including: chills, shivering, muscle aches, headache, sore throat, and a loss of taste and/or smell (Neuman, 2020). These were added to previously identified symptoms of fever (91-100%), cough (43-80%) and rhinitis (33-60%); 50-80% of reported cases reported an ill family contact and 30% reported nosocomial contact (Zimmerman & Curtis, 2020). Although much has been discussed in the media concerning gastrointestinal symptoms as a pediatric presentation, the reported study referenced had five subjects, leaving much to be discovered (Feder, 2020) . Emerging characteristics of serology and radiologic findings are listed in Table 5 .

Recent developments include concern of what is being called "COVID-toes." Initially, dermatologists had concern for children with pre-existing skin conditions, particularly those taking biologics or immunomodulators, who might be at increased risk for COVID-19-associated morbidity and mortality. Anecdotal reports were channeled to a registry development with the Global Rheumatology Alliance where more organized reports of pernio-like lesions on the toes began to coalesce. These lesions are characteristic of chilblains, but without any cold exposure.

Children report a burning sensation, pain, and/or tenderness lasting approximately two weeks.

There is no correlation currently between dermatologic manifestation and severity of illness (Forand, 2020) . As skin eruptions are common with viral illnesses of childhood, it is important to reassure parents COVID-toes seem to be an uncommon occurrence and to seek care with any health concerns (Cleveland Clinic, 2020). Concerned providers may report possible cases to www.aad.org/covidregistry. Also, of concern are reports of a Kawasaki-like syndrome (referred to by the CDC as multisystem inflammatory syndrome in children (MIS-C) in fifteen children aged 2-15 years hospitalized in New York City (Hester, 2020) . While none of these children have died related to MIS-C, five have required ventilator support and six have died from other COVID-19

complications. Reports of MISC-C in Europe include 20 cases in Italy, 20 in Paris, and 12 in Britain (Goldstein, 2020) . Some children appear to have signs of initial recovery followed by a secondary inflammatory response. Clinical implications include increased vigilance of potential manifestations of systemic vasculitis with appropriate clinical assessment and public health reporting for COVID-19 (Hester, 2020) . Parents can be reassured MIS-C still appears quite rare as a complication and in and of itself is not contagious (Steenhuysen, 2020) . Other vascular complications include higher than previously indicated coagulopathies, possibly initiated by a cytokine storm. Retrospective autopsy findings suggest mortality related to undiagnosed deep vein thrombosis. Further exploration is needed to investigate the molecular mechanism, incidence, and clinical implications of these findings (Bandyopadhyay et al., 2020).

The National Institute for Health (NIH) published the first COVID-19 Treatment Guidelines in May of 2020. There are some special considerations for pediatric populations, but the majority of guidance includes statements iterating insufficient data exists for or against use of pharmacologic therapies to treat COVID-19 infections in children (NIH, 2020). Treatment mainly consists of supportive care with provision of sufficient fluid and calorie intake along with oxygen supplementation and airway support. Most cases appear to be mild and can be treated at home following clinician determination of minor illness with appropriate anticipatory guidance and evaluation of available resources. Vitamin D supplementation may play a role in reducing the risk of COVID-19 infections, but there is insufficient evidence to support universal recommendation for children (Grant et al, 2020) .

Children who are ill enough to require hospitalization need observation for progression of respiratory distress, multi-system organ failure, and development of secondary nosocomial infections (Zimmerman & Curtis, 2020). Other COVID-19 pharmacologic treatment explorations include monoclonal antibodies, protease inhibitors, and RNA synthesis inhibitors (Zimmerman & Curtis, 2020). Chloroquine in particular has been widely publicized and publicly debated.

Emerging recommendations include prioritizing available supply for rigorous, scientific clinical trials, preventing treatment interruptions for those on chloroquine for chronic rheumatic diseases, and provision of clear messages with transparent and accurate interpretation of available data concerning COVID-19 treatment (Yazdany & Kim, 2020) .

If a child has a laboratory confirmed or clinically suspected case of COVID-19, isolation should be initiated. Discontinuing isolation can be test-based with two or more negative tests (with EUA approval from the FDA) more than 24 hours apart AND meeting requirements for symptom-based strategy. If testing is not available, isolation may be discontinued solely with a symptom-based strategy after a minimum of ten days from the onset of symptoms and more than three days from recovery (defined as a minimum of 72 hours afebrile without antipyretics and improvement in respiratory symptoms CDC, 2020f).

The world is waiting with bated breath for a COVID-19 vaccine. With more than 100 potential vaccines in development, safety and scientific rigor in the process will need to take highest priority (Altmann et al., 2020) . Many approaches are being studied including liveattenuated, inactivated, subunit, recombinant, viral vector, and DNA vaccines (Zimmerman & Curtis, 2020) . Vaccine development is a process which customarily takes 20+ years, but in the case of COVID-19, is being attempted in 12-18 months. Comparatively, other vaccines for children have gone through rigorous clinical trials with more than 70,000 subjects studied over four years or more, a difficult bar to clear in these conditions. In biologics, the process is the product, and it is essential the process is the same for every dose (Offit, 2020).

On May 4, 2020, the National Institute of Allergy and Infectious Disease announced the Human Epidemiology and Response to SARS-CoV2 (HEROS) study. More than 6,000 children in 2,000 families currently enrolled in NIH-funded pediatric research in 11 cities will participate in the effort to provide answers as to why most children with acute COVID-19 infection are not seriously ill. Families will be studied remotely with caregiver collection of specimens. Questions to be addressed include: 1) Do infection rates differ in children with asthma? 2) How many children infected with COVID-19 develop symptoms? and 3) Are children resistant to COVID-19 infection? (NIH, 2020).

Primary care access has been severely disrupted by restrictions implemented to prevent COVID-19 transmission. Challenges include limited PPE, limited availability of COVID-19 tests, patient workflow disruptions with closed waiting rooms and drive-through services, dramatic patient census drops and revenue shortfalls, and parental fears resulting in hesitance to present for care. In addition, rapid changes in telehealth in the last two months have exceeded changes made in the last two decades, with many practices quickly adapting from little-to-no telehealth to a majority of services being delivered remotely (Mostashari, 2020) . Long-term health impacts and outcomes remain to be seen.

Many PNPs have been called upon to care for young adults, converting inpatient critical care units to house persons aged into their 30s (Philips et al., 2020; Renke et al., 2020) . In times of emergency, this may be necessary. The National Association of Pediatric Nurse Practitioners (NAPNAP) asserted this is appropriate in certain circumstances but clarified certain conditions for consideration including: 1) individual state nurse practice acts should be consulted and followed, 2) the PNP has education and training to give appropriate care to the assigned patient, 3) safe harbor protections are in place to protect the PNP from being forced to accept unsafe assignment, and 4) care will transition to an adult provider as soon as possible (NAPNAP, 2020a).

Early estimates suggest measles vaccination rates have fallen up to 60% since onset of the COVID-19 pandemic (Dunleavy, 2020) . PNPs play an important role in promoting vaccination by encouraging and equipping families to stay on schedule to avoid vaccinepreventable illness (Goza, 2020) . NAPNAP recommends innovative solutions to provide safe opportunities to keep vaccination schedules on time including: 1) separating well and sick visit hours, 2) staggering appointment times, 3) closing waiting rooms, 4) reminding families about upcoming vaccines, 5) using every patient encounter as an opportunity to administer vaccines, and 6) administering as many simultaneous vaccines as possible (NAPNAP, 2020b) .

The world has changed on a 9/11 type of scale in the weeks following rapid spread of COVID-19. This is likely to change society in several ways with long-term implications still largely unknown. Professional experts in science, medicine, nursing, economics, business, journalism, and others are offering professional opinions of their expectations of world changes and paradigm shifts (Politico, 2020).

Schools are struggling to adapt rapidly, making high-stakes decisions with little information available. The American Academy of Pediatrics issued guidance regarding return to school to shape conversations around holistic health and equity (Hester, 2020) . NAPNAP (2020c) issued a position statement concerning child health and wellness during COVID-19.

Recommendations for families include: 1) supporting children as they ask questions about the pandemic, 2) close monitoring of child health and well-being with prompt contact of primary healthcare providers if changes are noticed, and 3) continuing to seek care in-person or using telehealth to maintain well visits and immunization schedules while receiving anticipatory guidance and necessary screenings. Recommendations for providers include: 1) increasing utilization of telehealth and telemedicine, 2) designing office experiences to support social distancing in a developmentally appropriate way, 3) increasing access to hand sanitation, 4) providing masks as indicated, 5) ensuring PPE is available for all staff, 6) advocating for mental health awareness and connection to resources, 6) referring families to credible sources of health information, 7) reminding families to present for well care, and 8) considering participation in research efforts. PNPs will need to continue to be active learners, adaptive and flexible while serving as trusted sources of information for families with children who concerned about immediate and long-term impacts and implications of COVID-19.

1. Which statement is most accurate concerning COVID-19 morbidity and mortality in the pediatric population?

a. Children have been disproportionately affected, with high rates of morbidity and mortality b. Children have lower rates of infection, but higher rates of death than adult populations c. Children with COVID-19 infection are mostly asymptomatic or mildly symptomatic d. Children are at much higher risk for acquiring COVID-19 than adult populations 2. Which of the following statements are true about non-pharmaceutical interventions (NPIS)?

Select all that apply. a. The goal of NPIS is to eliminate all mortality associated with COVID-19 b. Timing is critical to ensure least restrictive measures with greatest public health benefit c. Social distancing is the least effective measure to prevent the spread of COVID-19 d. Healthcare providers should emphasize personal accountability by establishing clear expectations and firm guidelines e. School closures are one of the most effective NPIS in helping slow the spread of COVID-19

3. Which of the following represents most appropriate mask usage according to CDC guidelines? a. Cloth face coverings for infants less than two years of age b. Surgical grade masks for school-aged children when in public c. Do-It-Yourself masks with scarves and coffee filters for primary care providers d. N-95 mask use for a pediatric nurse practitioner with a personal history of asthma 4. What actions should be taken to preserve PPE supplies for healthcare workers? Select all that apply. a. Use expired 3M N-95 masks for low-risk exposures* b. Removal, disinfection, and reuse of PPE is preferred over extended single periods of use c. Ideal PPE for COVID-19 care includes a new N-95 mask, gown, medical grade surgical gloves, and eye covers and/or a face shield* d. Visitors to the healthcare setting should be limited* e. Mask removal should be preceded and followed by strict hand hygiene* 5. What should healthcare or essential workers do to help prevent transmission of COVID-19 to household contacts? a. All essential or frontline workers should remain in self-quarantine for 30 days after providing care b. Soles of shoes worn in healthcare setting should be cleaned with bleach after removing c. Self-isolation at home should ideally occur in a separate room with private bathroom* d. N-95 masks and PPE gowns should be worn at home 6. If a child presents to the clinical setting with symptoms of COVID-19 compatible illness, what test should the pediatric provider order? a. RT-PCR nasopharyngeal swab b. Serology for COVID-19 antibodies c. Chest CT without contrast d. Home-testing kit with saliva collection 7. Which of the following clinical presentation scenarios is most concerning for possible COVID-19? a. 6-year-old with one episode of diarrhea, two episodes non-bilious emesis, and no ill contacts b. 18-year-old with a BMI >40 and prior history of Type II diabetes mellitus who presents with cough, chills, fever, and loss of smell* c. 12-year-old with sore throat, lymphadenopathy, and nausea d. 1-year-old with maculopapular rash to the hands, feet, and buccal mucosa 8. What is the most appropriate response to parental concerns over multisystem inflammatory syndrome in children (MIS-C)? a. This is a life-threatening illness becoming common in children b. This is a rare and usually treatable complication from a viral illness c. This is a contagious illness that can easily spread from child-to-child d. Kantis, C., Kiernan, S., and Bardi, J.S., 2020, Think Global Health (https://www.thinkglobalhealth.org/article/updatedtimeline-coronavirus) . "WHO Timeline COVID-19, by the World Health Organization, 2020 (https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19). 

What policy makers need to know about COVID-19 protective immunity. The Lancet. Advance online publication

Severe COVID-19 during pregnancy and possible vertical transmission

Hospitals and health systems face unprecedented financial pressures due to COVID-19

COVID-19 pandemic: Cardiovascular complications and future implications

Impact of non-pharmaceutical interventions on documented cases of COVID-19. medRxiv. Advance online publication

Autopsies of COVID-19 patients reveal clotting concerns

Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster

Strategies for optimizing the supply of facemasks

Discontinuation of transmission-based precautions and disposition of patient with COVID-19 in healthcare settings

Are COVID toes and rashes common symptoms of the coronavirus? Why are we hearing so much about them these days? Cleveland Clinic

Miscarriage and maternal mortality in pregnant patients

Measles vaccinations in U.S. children fall up to 60 percent since pandemic, CDC says

Digestive issues were an early symptom of coronavirus for 5 children who needed hospital treatment, a study says

Dermatology expert weighs in on 'COVID toes,' tracking dermatologic symptoms of COVID-19

Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths

Coronavirus in african americans and other people of color

15 children are hospitalized with mysterious illness possibly tied to COVID-19. The New York Times

AAP statement on new data showing declines in childhood immunizations

Promoting healthy movement behaviours among children during the COVID-19 pandemic. The Lancet Child & Adolescent Health

AAP offers guidance for reopening schools

The science of social distancing

Updated: Timeline of the coronavirus. A frequently updated tracker of emerging developments from the beginning of the novel coronavirus outbreak

Reducing risks from coronavirus transmission in the home-the role of the viral load

Be confident protecting yourself and providing the best care to your patients during this COVID-19 pandemic

American Nurses Association

The science of social distancing

collapse National Association of Pediatric Nurse Practitioners [NAPNAP]. (2020a, April)

Study to determine incidence of novel coronavirus infection in U.S. children begins

COVID-19 vaccine update: Will we have the vaccine any time soon? Is the immune system induced by the vaccine really protective?

Rapid implementation of an adult COVID-19 unit in a children's hospital. The Journal of Pediatrics

Coronavirus will change the world permanently. Here's how

What is R 0 ? Gauging contagious infections. Healthline

COVID-19 Testing: Possibilities, challenges, and ensuring equity

Utilization of pediatric nurse practitioners as adult critical care providers during the COVID-19 pandemic: A novel approach

High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2

An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Archives of Pathology and Laboratory Medicine

Interpreting diagnostic tests for SARS-CoV-2

Insight into FDA's revised policy on antibody tests: Prioritizing access and accuracy

Three U.S. children with COVID-18 have rare inflammatory syndrome

WHO timeline-COVID-19

Pediatric characteristics of 2019 novel coronavirus: Review of available

Use of hydroxychloroquine and chloroquine during the COVID-19 pandemic: What every clinician should know. Annals of Internal Medicine

Coronavirus infection in children including COVID-19: An overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children