2020 Year in Review (Jimenez, Green 2/24/2021)

Great thanks to Dr. Douglas Jimenez and Dr. Cherie Green for their Grand Rounds 2020 Year in Review. Much of the presentation focused on-- you guessed it-- COVID (that is basically what ALL our lives revolve around these days), with select bonus points on a few other hot topics. Dr. DJ covered the latest and greatest on COVID in OB and Dr. Green did a potpourri of COVID in kids. 

The COVID literature is evolving literally day by day, so please take this summary as a point in time update. Our understanding of the disease will continue to evolve as we get more data/studies/literature on these topics. For a video recording of this presentation, click here: VIDEO.

Here are my summary points from this presentation:

COVID OB Management in 2020:

• Pregnant women appear to be at higher risk for severe COVID illness and death
• 5-6% of pregnant women with COVID are hospitalized
• 3x risk ICU, 2.9x risk intubation, 1.7x risk of death

• Pregnant women with severe/critical COVID disease also appear to be at increased risk for preterm birth and pregnancy loss
• 10-25% preterm delivery (induced + spontaneous)
• 60% preterm delivery in critical illness
• Per SMFM, a history of COVID disease is NOT itself an indication for antenatal testing
• use routine indications for antenatal testing
• however, a 32 week growth ultrasound may be considered
• Is COVID an indication for delivery?
• asymptomatic/mild infection: COVID is not an indication for delivery, though can consider delivery if >39 weeks
• severe/critical illness: it is reasonable to consider delivery but mechanical ventilation alone is not an indication for delivery
• if EGA< 32 weeks and considering delivery, also consider proning, ECMO, etc
• Is COVID vaccination recommended in pregnancy?
• Due to lack of data in vaccine trials, the WHO has been "lukewarm" about recommending COVID vaccine, recently adjusting their recommendation to recommend vaccinating women at high risk (e.g. healthcare workers) and those with comorbidities that put them aat increase risk for severe illness (e.g. diabetes, obesity).
• However, it is important to note that the Maternal Immunizations Task Force (which includes many large and reputable organizations including: ACOG, AAFP, IDSA, AAFP) specifically recommend that COVID-19 vaccine be made available to all pregnant women
• they say it is unethical to not offer vaccine knowing that pregnancy is a risk factor for more severe COVID illness
• this should be a shared decision-making conversation with provider on risk vs, lack of safety data
• What about Breastfeeding and COVID?
• CDC recommends ALL women with active COVID continue to breastfeed-- no evidence of COVID in breast milk, benefits>>risks
• should use face mask and hand hygiene with every feed
• Labor support and COVID
• Policies surrounding limitation of support people in labor disproportionately harm women of low SES and women of color, who are also disproportionately affected by COVID-19
• less labor support--> more operative delivery, longer labors, etc
• We should be mindful of these policies and do our best to weigh risks/benefits in our advocacy work

Bonus Pearl: Alcohol in pregnancy. Dr. DJ reviewed a paper from Australia  (Association of Perinatal Alcohol Exposure with Psychological, Behavioral, and Neurodevelopmental Outcomes in Children from the ABCD Study, American Journal of Psychiatry  2020), which found a dose-dependent correlation between ANY alcohol use in pregnancy and psychological/emotional problems and behavioral problems. 

• 25% increased likelihood of an ADHD in children exposed to heavier levels of alcohol (approximately 36 drinks) in the first 6-7 weeks of pregnancy.
• Heavier alcohol use during early pregnancy also associated with rule breaking behavior and aggression, 30% higher risk of the child being diagnosed with oppositional defiant disorder

COVID + kids 2020:

Dr. Green reviewed several studies on the impact of COVID on our children. Here are her pearls:

• 2020 study out of China, 123,000 children looking at myopic changes with a 5 month lock down
• in children ages 6-8 years, significant number of children had a clinically significant myopic shift (-0.3 diopters) with higher prevalence of myopia in children compared to previous years
• this was not true in older children (ages 9-12)
• conclusion: home confinement seemed to have a significant effect on vision and myopia rates in children ages 6-8, perhaps because this is a more critical developmental period for this problem
• Clinical pearl: every 20 minutes, have children look up and way from the screen for at least 20 seconds, 20 feet away
• Mental health in children during the Pandemic
• Clark County, Nevada: 19 deaths by suicide
• Riley Hospital, Philadelphia: 250% increase in hospitalization for childhood suicide attempts
• CHO: double rate of childhood suicide attempts compared to 1 year ago
• CDC reports increase in mental health ED visits, sustained since March 2020 (see image)
• 25% increase in children 5-11, 31% in children 12-17, compared to the same period one year prior
• Clinical pearl: Ask ALL children how there mental health is doing during the pandemic. Particularly for teens, consider the use of APPS: including CALM, headspace, COVID coach
• 
• The Safety of School Reopening 

• SARS-CoV-2 infection and transmission in educational settings: a prospective, cross-sectional analysis of infection clusters and outbreaks in England Ismail et al, Lancet December

• prospective study, strict infection control precautions, small groups, low community prevalence
• 1,000,000 students, 500K staff--> 343 total cases of COVID (130 in children, 213 in staff)
• 55 total outbreaks (outbreak defined as more than 1 person, most involved just 2), probable staff to staff in 26 of those outbreaks
• no children hospitalized, 3 adults hospitalized, 1 adult died (contracted from home)
• Summary: SARS-CoV-2 infections and outbreaks were uncommon in educational settings during the summer half-term in England. The strong association with regional COVID-19 incidence emphasises the importance of controlling community transmission to protect educational settings. Interventions should focus on reducing transmission in and among staff”

• Incidence and Secondary Transmission of SARS-CoV-2 Infections in Schools

  Zimmerman et al, Pediatrics 2021
• 11 districts in North Carolina, 100K students x 9 weeks
• 32 additional cases of COVID via school transmission
• No instances of child to adult transmission
• Summary:

• In the first 9 weeks of in-person instruction in NC schools, secondary transmission of SARS-CoV-2 was extremely low overall, and only involved staff to staff transmission. “Our data support the concept that schools can stay open safely in communities with widespread community transmission.”

With mitigation in place (distancing, handwashing, ventilation) schools do not appear to be contributing widely to the spread of COVID in the community. They CAN be reopened safely and prevent some of the unfortunate other unsafe conditions for children, particularly our most vulnerable children.