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

[joyouter]

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

Thanks for this. I am certain that many share your frustration. There are some key points to remember when considering the epidemiological profile of West Africa. ( were you referring to this part of the continent?-not sure)

The healthcare picture is not standardized, there are some state hospitals who try to do their best however, equipment is not up -to date or lacking, staffing can be short with rudimentary trained staff in greater numbers than RNs. Many hospitals are private and many cash strapped citizens have to pay up front for care for themselves and family, ie. children. If you do not pay, you will not be released or some similar reminder for the unfortunate patient that payment must be made.

This in a climate which is recognized for deadly infections such as dengue, yellow fever, tomba fly infections, types of malaria with the most deadly being. malaria falciparum ( cerebral malaria - treatment is vital and spinal taps and or intrathecal tx are most effective, due to the limited transport across the brain barrier of many medications. Spinal taps and treatments are not really recommended thus westerners are medevaced ASAP. Local citizens may not be so lucky.

The key to all of this is economics. ie. having enough money to care for a family, good regular hygiene, safe disposal of waste and provision of balanced regular nutritious meals. This builds the blocks of good immune systems and the ability to fight infections.

Children can be afflicted with other types of malaria such as plasmodium malariae or plas. simplex which will re occur periodically and affects on-going health status. The local diet can be rich in veg. and fruit, but the favorite is yam and cassava which are filling but only part of the cycle of a balanced diet.

Clean water is always a challenge and amebic illnesses remain endemic. Contamination is an ongoing cycle and affects the liver and intestinal tract, thereby negatively affecting absorption of nutrients. The lack of which over time, then becomes a vicious cycle affecting growth, development and immune response..

One cannot blame western staff on the condition of children in W. Africa. They are simply trying to bring about positive change and support in a never-ending cycle of need and to improve the lives of many people in that country. The problems can be based on any number of reasons, climate, incredible jungle growth fed by a rich eco system, plenty of non-potatble water, poverty and poor government.

It is not the western care of children there rather the underlying conditions of poverty, limited education and lack of good leadership which provokes problems and epidemics of every type.

We, as western nurses have enjoyed steady, nutrition and sanitation since birth. We have not had civil wars in our homes and thus our health status and ability to fight disease is quite different to most in W. Africa. That could explain in part why our nurses return home and appear in good health. One other reason offered by NYH professor is the lack of invasive procedures in the field in comparison to the intensive, invasive practice in western hospitals with intubation, dialysis, etc. which actually exposes our nurses in the west to greater risk of infection / contamination here.

Thanks for listening.

[adventure780, BSN, MSN, RN, APN]

this again vertifies how important it is to document and ask about travel history for our patients that we admit everyday. I currently work in subacute and long term care settings, our adminstration has initated the Ebola questionare in admission packets. Some of my co-workers have stated we receive patients that are more stable however symptoms can occur even days after exposure. Sometimes patients are only in the hospital for a few days before being transferred to the subacute or long term care setting. Also they are patients who just go out for 24 hour observations. How many times have I received a patient that had a fever on admission?, One day it was three in a row! So whether it''s peds, older adults or the general population, anyone needs to be asked about their travel risk and be monitored if they arrived to you with a fever.

[lamazeteacher]

As a retired "pediatric nurse consultant" and health (PHN), I'd like to share experiences I had at a hospital for communicable diseases in Montreal, Quebec.