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
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 10Ã¢Â€Â”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