This week doctors have been alerted to watch out for a rare but very serious new illness among children. The numbers affected appear to be very small, and research is underway to determine whether or not it is linked to Covid-19. Most children catching the coronavirus thankfully recover in full without any serious health effects.
Yet with concern that children are among those who could become ‘collateral damage’ from the crisis, what actions could be taken now to make a difference to protect the youngest members in society from avoidable harms?
One of the first things that is needed is an enhanced process for identifying very vulnerable children that require the highest measures of social protection – known as ‘shielding’. Thousands of people appear to have been missed off the government’s ‘high risk’ list for the virus, which could mean children too.
Personal communication from one community paediatric team found that only a small proportion – approximately 1 in 4 children – identified as needing shielding via clinical review had received a letter formally recommending such measures. Doctors there had reviewed a list of seriously ill children under their care to identify those where shielding was clinically indicated based on the child’s health conditions, and found many children who appeared to have been missed.
So what might help? The current approach could be usefully supported by a rapid review by paediatricians of children under their care or, where that is not practical, automated searches of GP records for children with multiple or complex health conditions.
Keeping vulnerable children safe
Protecting the most vulnerable children – including looked-after children, disabled children and young carers – must continue to be seen as a policy priority. With calls to the National Domestic Abuse hotline up by a worrying 25% since the lockdown started, children on ‘at risk’ registers are an important group to focus upon.
That means protecting the staffing of children’s services – including mental health and social services – so that those essential to protecting children’s health continue to be available. CAMHS referrals in some areas are being declined because of the virus, and where professional support is available to young carers or children with mental health problems, for now it is mainly limited to phone calls.
With families and children’s services creaking under increasing strain, one solution might be an "army of volunteers for vulnerable kids", as suggested by the Children’s Commissioner. They might be people who are able to help social services and schools reach children and families, check in on what is going on, while offering support to those families.
Avoiding delays in diagnosis
It is vital that parents with a seriously ill child know how they can get help. Seeing a doctor at a GP practice is generally the first port of call for parents with an ill child, but this route of access has changed beyond all recognition. NHS England has instructed practitioners to do remote consultations “as a default”, with GPs reportedly seeing only seven in every 100 patients in person.
It is hard to downplay the clinical value of physically seeing a really sick child, and we must find a way to provide fast access to ‘face-to-face’ medicine where it is still needed. Key here is to communicate that practices are still open, with GPs keen to stress they are safe to visit. With clinical commissioning groups increasingly concerned that people are not coming to seek care from GP practices when it is urgently needed, more effort may be needed to ensure this message is clear.
Parents also need to know that, in most cases, the benefits for a seriously sick child of going to A&E are likely to outweigh the risks of exposure to Covid-19.
An intelligent plan
While services for life-threatening conditions such as childhood leukaemia are rightly being prioritised, a growing volume of ‘sub-acute’ work for children with serious long-term conditions is being put on ice.
This includes delays in blood tests needed to monitor disease flares and medication-related harms among children with autoimmune conditions, cuts to physiotherapy for children with physical disabilities, and delays in the treatment of bacterial lung infections among children with cystic fibrosis. Many services for chronically ill children have been drastically reduced or temporarily cut altogether, which may go on for some months.
Clinical teams will now need to develop an intelligent plan for catching up on the work that has fallen on the back burner.
With many hospitals now unexpectedly quiet after mothballing normal operations in preparation for the coronavirus, there is an urgent need to develop streams of work that benefit patients but which are not associated with increased clinical risk due to Covid-19 infection. And which can be flexibly stepped up during quiet spells and switched off if Covid-19 patient numbers increase.
That could include clinical audits, review and triage of incoming referrals, taking histories from new patients via phone or video and identifying those needing immediate priority action – desk-based tasks that mean when clinical work properly resumes it can do so as quickly and efficiently as possible.
A coordinated effort is also needed across specialities working with children to set priorities for post-Covid recovery, and make sure that in the rush to catch up, the focus is on resuming services and interventions that make the biggest difference to improving and protecting children’s health.
Acting now to protect children from avoidable harms
There have been rapid service innovations (particularly in primary care) that, together with delays and reduced access to children’s services, not only bring a range of future opportunities for more focused and nimble working but also risks, unintended consequences and potential harms.
Some of these harms will be avoidable, and can be mitigated by actions taken now to identify vulnerable children, keep essential services in place, avoid delays in diagnosis, and make an intelligent plan for catching up in the months ahead.
Paddison C (2020) “Reducing avoidable harms to children during Covid-19: what actions are needed?”, Nuffield Trust comment.