Five Key Points About Multisystem Inflammatory Syndrome in Children

COVID-19 has proven to be a relentless enemy. Mortality and morbidity in elderly patients with co-morbidity is high. A large number of young and healthy individuals have succumbed to this disease, as have elderly patients with multiple co-morbidities who have survived expectations.

The variable during this pandemic is children. Most children who develop COVID-19 show mild symptoms or are asymptomatic. A small proportion develop an inflammatory syndrome called multi-system inflammatory syndrome in children, or MIS-C.

Not quite Kawasaki

Initially identified as Kawasaki disease (KD) when it was first seen in the New York City / Northern New Jersey area, MIS-C appeared presenting large numbers of out-of-norm patients combined with a turn to the age group that forced doctors to press the pause button. They started testing these patients and found that they were all COVID positive. Since then, MIS-C has been identified all over the United States, wherever we see COVID in pediatric patients.

Kawasaki disease is an acute febrile illness of unknown cause, mainly affecting children under 4 years of age. Clinical signs include fever, rash, swelling of the hands and feet, irritation and redness of the whites of the eyes, swollen lymph nodes in the neck, and irritation and inflammation of the mouth, lips and throat. It is one of the leading causes of acquired heart disease in the US, with serious complications such as coronary aneurysms, decreased myocardial contractility and heart failure, myocardial infarction, arrhythmias, coronary artery dilatations and peripheral arterial occlusion. Children with KD can experience severe shock or cardiac arrest.

MIS-C presents in the same way as KD, but MIS-C has been seen in patients into the teenage years. Some of these children will improve without treatment, and others will need intensive care.

Signs and Symptoms

The signs and symptoms of MIS-C are slightly different from COVID, and parents may be infected with either. Any child with the following signs / symptoms should be considered to have COVID:

Fever Abdominal pain Vomiting Diarrhea Neck pain Rash Bloodshot eyes Feeling extra tired

The unpredictability of COVID is most troubling to EMS. Healthy people, including children, ended up in the ICU and died. For the few children who develop severe or life-threatening acute respiratory presentations, assessment and treatment of symptoms are vital in the preclinical setting. A serious illness would develop in children with the following signs and symptoms:

Difficulty breathing Pain or pressure in the chest that does not go away New confusion Inability to wake up or stay awake Pale, gray or blue colored skin, lips or nail beds, depending on skin color Severe abdominal pain

Treatment in the field

If your patient has mild symptoms, monitor vital signs and pay particular attention to their pulse oximetry. If necessary, provide oxygen and transport in a comfortable position. Remember that children have very efficient compensation mechanisms, but when they decompensate, it’s like dropping a stone from a tall building.

As with all COVID patients, treat the signs and symptoms: poor ventilation, insufficient oxygenation, and low blood pressure / poor circulation. (You can memorize these components using the VIP reminder, for breaths / oxygenation, infusion, and pressors.)

As with all pediatric ventilation, maintaining an airway and oxygenation are our mainstays. With everything COVID-related, any number for the SpO2 below 92% is a precursor to rapid deoxygenation. If we wait for patients to complain of breathlessness, it may be too late and we will be surprised by pulse oximetry readings below 84%. Ventilations and oxygenation with high flow oxygen are necessary.

Before proceeding to pressors, volume infusion with a conservative fluid approach is critical. Use crystalloids but do not bolus patients too quickly. The fluid you administer, if it is too much or too fast, will increase the leakage into the alveoli.

If you need to switch to vasopressors, adrenaline or norepinephrine are the preferred pressors for pediatric patients. The Society of Critical Care Medicine strongly discourages the use of dopamine. Push-dose pressors or infusion via an IV pump is best.

Pediatric patients with signs and symptoms of MIS-C should be transported to a pediatric hospital for evaluation and treatment. If none is available, a hospital with a pediatric ED is preferred. Clinical progression may be uneven at best, and pediatric patients may require more sophisticated resources with rapidly progressing disease, so making sure the patient ends up in the right setting is important.

MIS-C in My Community

You will absolutely see this. This is one of the reasons for the initiation of clinical studies with pediatric patients and COVID vaccines. Cases of COVID and MIS-C in children have increased as schools reopened and restrictions removed. The CDC has reported that the group of patients who saw the most cases during this current wave is between the ages of 10 and 20.

Long-term complications

We are still learning about MIS-C and how it affects children, so we don’t know why it makes some children sick and others not. We also don’t know whether children with certain health problems are more likely to contract MIS-C.

When we talk about “long-haul vehicles”, that is a misnomer. Recovery is poorly understood. What does COVID-19 recovery mean? We have seen 36 million infected people, many of whom have developed cardiomyopathies, pulmonary fibrosis, frosted glass in the lungs, end organ damage from coagulopathies, and neurological abnormalities – strokes, for example. Some patients who have now recovered need a heart or lung transplant. The question we grapple with is: are these cases the outliers or are they part of COVID’s long-term journey?

Currently, we do not know the long-term implications of COVID-19 as far as children develop multi-system inflammatory syndrome. We have seen children get seriously damaged hearts from COVID. We may not know or understand the full impact of COVID-19 on pediatric patients in the years to come.

Resume

We will see MIS-C in our communities. It looks like Kawasaki disease, the only difference is that we see it in children into the teenage years. Identify and manage the life-threatening warning signs of cyanosis, chest and abdominal pain, confusion, and decreased consciousness. Prioritize airway, breathing, and circulation using the VIP approach. If possible, transport children with MIS-C to a children’s hospital or an institution with a pediatric ED.

Resources

Abrams JY, Godfred-Cato SE, Oster ME, et al. Multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome Coronavirus 2: a systematic review. J Pediatr, 2020; 226: 45-54 [epub ahead of print].

Association of American Medical Colleges. Coronavirus (COVID-19) Resource Hub, www.aamc.org/coronavirus-covid-19athedral-hub.

Ebina-Shibuya R, Namkoong H, Shibuya Y, Horita N. Multisystem Inflammatory Syndrome in Children (MIS-C) with COVID-19: Insights from Concurrent Familial Cases of Kawasaki Disease. Int J Infect Dis, 2020 Aug; 97: 371-3.

Esposito S, Principi N. Multisystem inflammatory syndrome in children related to SARS-CoV-2. Paediatr Drugs, March 2021; 23 (2): 119-29.

Feldstein LR, Tenforde MW, Friedman KG, et al .; Overcoming COVID-19 Investigators. Characteristics and Outcomes of American Children and Adolescents with Pediatric Multisystem Inflammatory Syndrome (MIS-C) Compared to Severe Acute COVID-19. JAMA, 2021 Mar 16; 325 (11): 1.074-87.

National Education and Training Center for Special Pathogens. Novel Coronavirus (COVID-19), https://repository.netecweb.org/.

National Institutes of Health. Care for critically ill adult patients with COVID-19, www.covid19treatmentguidelines.nih.gov/critical-care/.

Office of the Assistant Secretary for Preparedness and Response, Technical Resources, Assistance Center and Information Exchange. COVID-19 resources, https://asprtracie.hhs.gov/COVID-19.

Pan American Health Organization. COVID-19 Recommendations: Prehospital Emergency Medical Services (EMS), www.paho.org/en/documents/covid-19-recommendations-prehospital-emergency-medical-services-ems.

World Health Organisation. COVID-19 Clinical Management: Living Guidance, www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1.

Daniel R. Gerard, MS, RN, NRP, is EMS Coordinator for Alameda, California. He is a recognized expert in the delivery and design of EMS systems, EMS / healthcare integration and service models for out-of-hospital care.

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