Ebola: What About The Children?

[ElizabethStoneRN]

A wake up call spurs many questions

With the recent news of a 5 year old in New York being tested for EVD, many questions are now raised for emergency nurses nationwide, because the evidence-based recommendations and decision rules that we take for granted don't exist to guide the treatment of a child with EVD. How likely is it that this child in New York, or another child in the U.S., will have EVD? Would a child present with the same symptoms as an adult? How would treatment need to be modified for pediatric patients, who are already at a higher risk for hypovolemia and electrolyte abnormalities, two of the most common complications of EVD? And how in the world would we as nurses provide developmentally appropriate support and care for a child if they required strict isolation and had to be separated from their family?

Pediatric emergency nurses embrace the concept of family at the bedside and involve them in patient care, even during critical situations. Pediatric patients with infectious diseases that require isolation are almost always isolated along with a family member. However, it is currently not clear as to whether parents or caregivers would be placed in isolation with a child infected with EVD.¹ Forcing family members to be separated from a terrified, ill child is something I hope I never to have to do. It is something I'm not sure I could do.

In light of this current outbreak of EVD, which the World Health Organization (WHO) has declared to be a Public Health Emergency of International Concern², I decided that I wanted to see what I could find online regarding EVD in children.

How common is EVD in pediatric patients?

The "data" that we have grown to rely upon in healthcare is scarce for EVD, because until now, EVD outbreaks have only occurred in isolated, resource-poor areas with very little capacity for data collection or research. The current outbreak, which is the largest in history, actually began in a pediatric patient. "Patient zero" (the initial case) for the current outbreak of Ebola is believed to be a 2 year old child who died in Guinea in December 2013.³

In past outbreaks and in the current one in Guinea, based on available data, children and adolescents have accounted for a relatively small number of infected individuals, ranging from 9% to 18% of total confirmed cases.⁴ One factor believed to contribute to this is the fact that children in this outbreak were often kept away from sick family members. Caregivers for those who were infected were almost always adults, both at home and in the hospitals.

However, among those children who did contract EVD in at least one earlier outbreak, those

It is not uncommon for infectious diseases to vary in severity depending on the age of the patient.⁶ One example of this is tuberculosis, which affects children and adolescents to a milder degree than it does adults. Based on the available literature, this may be the case with EVD. Many children, for example, seem to be spared from the hemorrhagic manifestations of EVD. In the 2000-2001 Ugandan outbreak, the largest outbreak on record to that date, 100% of the children infected had fever but only 16% had hemorrhage.⁴ This is less than half the typical rate of hemorrhagic manifestations in EVD-infected adults (30-40%).⁷

Nursing Considerations

Children with EVD initially present with similar symptoms as adults with EVD. These symptoms may include fever, headache, abdominal pain, myalgias, vomiting and diarrhea, similar to many other common childhood illnesses. This highlights the importance of obtaining a travel and possible exposure history on every patient, including children. Health care professionals should continue to maintain a high index of suspicion for EVD when evaluating ill children from the high risk regions, but remember to also consider the other common diseases which are endemic in West Africa such as malaria, measles, and typhoid fever⁴.

Fortunately, we are learning more about EVD with every case that is diagnosed in the United States, because our nation has the resources to collect extensive data. Healthcare and professional organizations are already utilizing this data to produce the most up to date guidance for front line emergency healthcare providers. A new, concise CDC algorithm, "Identify, Isolate, Inform: Emergency Department Evaluation and Management for Patients Who Present With Possible Ebola Virus Disease",⁸ was developed by an American College of Emergency Physicians (ACEP) expert panel which included representation by the Emergency Nurses Association (ENA), my professional organization.

We don't have all the answers, especially when it comes to pediatric EVD care, but we already have access to more information than just one month ago. If a child presents to my emergency department with symptoms and risk factors for EVD, I will now feel a little more informed, and a little more confident that we are not simply "winging it".

Most of the resources below are available online, free of charge.

Elizabeth Stone Griffin, MSN, RN

Pediatric Emergency Nurse

References / Resources

1. Byington, C. Ebola and children: identifying and meeting their needs. AAP News, originally published online October 17, 2014. Accessed from AAP News on October 28, 2014

2. World Health Organization. WHO statement on the Meeting of the International Health Regulations Emergency Committee regarding the 2014 Ebola outbreak in West Africa. WHO | World Health Organization

3. Baize S, Pannetier D, Oestereich L, et al. Emergence of Zaire Ebola virus disease in Guinea. N Engl J Med. 2014;371(15):1418-1425.

4. Peacock G, Uyeki TM, Rasmussen SA. Ebola Virus Disease and Children: What Pediatric Health Care Professionals Need to Know. JAMA Pediatr. Published online October 17, 2014. doi:10.1001/jamapediatrics.2014.2835.

5. United Nations International Children's Emergency Fund. UNICEF Guinea: Humanitarian Situation Report, 29 August 2014. September 5, 2014. UNICEF Guinea: Humanitarian Situation Report, 5 September - Guinea | ReliefWeb. Accessed October 28, 2014

6. McElroy AK, Erickson BR, Flietstra TD, Rollin PE, Nichol ST, Towner JS, et al. Biomarker correlates of survival in pediatric patients with Ebola virus disease. Emerg Infect Dis [internet]. 2014 Oct [obtained 10/27/2014]. Biomarker Correlates of Survival in Pediatric Patients with Ebola Virus Disease - Volume 20, Number 10—October 2014 - Emerging Infectious Disease journal - CDC doi: 10.3201/eid2010.140430

7. McElroy, A. and Spiropoulou, C. Correspondence. Journal of Infectious Diseases Advance Access published September 24, 2014. Accessed online 10/28/2014: Reply to Fedson

8. Centers for Disease Control and Prevention. Identify, isolate, inform: emergency department evaluation and management of patients with possible ebola virus disease. Accessed online 10/28/2014: Redirect| Ebola Hemorrhagic Fever | CDC

[traumaRUs, MSN, APRN]

Great article and very timely. We are asking travel and exposure history in everyone even visitors nowadays.

[tnbutterfly - Mary, BSN]

Elizabeth, thank you for this fantastic and informative article. It is scary to even think about children suffering and dying from Ebola. But, we must remember that many children have died in Africa.

Thanks for the wake up call!

[sirI, MSN, APRN, NP]

Welcome, Elizabeth, and thank you for the Article. Good writing.

[FranEMTnurse, CNA, LPN, EMT-I]

Very informative. Thank you for posting this. information.

[Julie Reyes, DNP, RN]

Wow! Great info! We had the same discussion at our pediatric hospital - what to do with the parents of the ill child? Someone said one of the parents could volunteer to stay with the child, and we would decide if the parent would don full PPE (most likely would). However, we all know that the PPE is very hot and how long are we willing to allow the parent to remain in the suit? How long would the parent actually STAY in the suit? (we have all experienced the family who has a child on contact/droplet/airborne precautions and the parents remove their ppe when the nurse isn't looking....)

I don't know what is realistic as far as that goes. Depending on how sick the child was would depend on how much the child would know the parent is not there, I suppose. The more sick - the less aware.

Then we have to consider - who is going to be monitoring the parent as they don/doff the PPE. And how often will the parents want to come in/out of the room, etc. It is a nightmare to consider.

Great article!!

[Lev, MSN, RN, NP]

Very well written, informative article.

[ElizabethStoneRN]

Thank you everyone for the great feedback and warm welcome! I really appreciate it :)

[NewYorkerGirl]

(we have all experienced the family who has a child on contact/droplet/airborne precautions and the parents remove their ppe when the nurse isn't looking....)

I'd suggest a video-monitor room to prevent that from happening.

[joyouter]

EXcellent article- very informative, and raises reflection on the pediatric population exposed to, at risk and victims of Ebola Virus Disease.

I was struck by the lack of information based on the very rudimentary level of care available in W. African countries currently affected. I am wondering if immune testing has been carried out or is this even possible there given that the immune response in children does not mature until roughly 6 yrs old or later and is dependent on development of good overall general health, nutrition, sanitation on an ongoing basis. As you know, the nutritional status is directly related to economic reality and is linked to previous health and sanitation. . Having worked in W.Africa a number of years ago ( 3 years) it is also interesting to consider the underlying high risk of malaria in these regions plus guardia, dengue, yellow fever and other tropical diseases endemic to West Africa.

Young children are often affected with any of the above and sanitation, especially clean water, is being addressed by govt. but remains a challenge in remote isolated areas. The hot, humid jungle climate also contributes especially with rapid dehydration. Gastro is very common and possibly could cloud diagnosis of EVD as could malaria which starts with fever, until it is too late for active treatment. This then becomes palliative, unless the patient is fortunate.

Your references and article really raise awareness and hope to see more. Thank you for this.

Joy

[ElizabethStoneRN]

I am wondering if immune testing has been carried out or is this even possible there given that the immune response in children does not mature until roughly 6 yrs old or later and is dependent on development of good overall general health, nutrition, sanitation on an ongoing basis.

Joy- great question! actually there has been some limited testing done - see excerpt below from one of the references to the article which discussed research performed by an international response team during the 2000-2001 Gulu outbreak. the results of this study were quite interesting and certainly seem to be a great foundation for further research and treatment:

"Pediatric patients who survived had higher levels of the chemokine regulated on activation, normal T-cell expressed and secreted marker and lower levels of plasminogen activator inhibitor 1, soluble intracellular adhesion molecule, and soluble vascular cell adhesion molecule than did pediatric patients who died. Adult patients had similar levels of these analytes regardless of outcome. Our findings suggest that children with EVD may benefit from different treatment regimens than those for adults".

( excerpt from : McElroy AK, Erickson BR, Flietstra TD, Rollin PE, Nichol ST, Towner JS, et al. Biomarker correlates of survival in pediatric patients with Ebola virus disease. Emerg Infect Dis [internet]. 2014 Oct [obtained 10/27/2014]. [COLOR=#003366]http://dx.doi.org/10.3201/eid2010.140430)

[fnkEchkn]

What I'm sick of is every disease that comes out that is getting world wide attention always originates in Africa..

Many kids are dying in Africa from this disease but a nurse comes back here she survives..makes me wonder what kind of care the patients are getting in Africa.