22 minute read
Impact of COVID-19 on the Pediatric Population
Jessica Y. Lee DDS, MPH, PhD, is the Demeritt distinguished professor of pediatric dentistry and chair of the division of pediatric and public health at the University of North Carolina. She is also a professor in the department of health policy and management in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. Dr. Lee is the current president of the American Academy of Pediatric Dentistry. Conflict of Interest Disclosure: None reported.
Janice A. Townsend, DDS, MS, is the chief of pediatric dentistry at Nationwide Children’s Hospital and chair of the division of pediatric dentistry at The Ohio State College of Dentistry. Dr. Townsend previously served as an associate professor and chair of the department of pediatric dentistry at the Louisiana State Health Sciences Center School of Dentistry, where she is also the Blue Cross Blue Shield of Louisiana professor in pediatric dentistry. She is a diplomate of the American Board of Pediatric Dentistry. Conflict of Interest Disclosure: None reported.
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Eva C. Ihle, MD, PhD, is the interim medical director of the division of infant, child and adolescent psychiatry at the Zuckerberg San Francisco General Hospital and Trauma Center. She also directs the hospital’s program to enhance access to psychiatric care for underserved populations by partnering with primary care clinics. Dr. Ihle studied social behaviors in songbirds and a mouse model for autism. She also has examined the mechanisms that support health and well-being in individuals under stress. Conflict of Interest Disclosure: None reported.
ABSTRACT
In March 2020, the U.S. declared a state of emergency and stay-at-home orders were issued. This included school closures and limitation of dental practice to emergency treatment only. While public health measures were very much needed, it was not without unintended consequences. School closures only compound the economic, health and achievement inequities, disproportionately affecting disadvantaged children, which also includes access to dental care. As we emerged from the stay-at-home orders, dental practices have had to adapt and evolve.
Keywords: COVID-19, pediatric dentistry, child health
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The COVID-19 pandemic is a generation-defining event with unprecedented human, social and economic implications. This global health crisis has become the focal point of concerted efforts by international and state agencies, industry and the civil society. Amid the pandemic, optimizing care and health outcomes for COVID-19 patients and their communities remain top priority — at the same time, operating in “the new normal” is a pressing challenge for virtually all sectors. COVID-19 is arguably the most disruptive change that health care education has ever encountered. Within this adverse and rapidly changing environment, pediatric health care providers are faced with unique challenges that not only affect their clinical practices but also the well-being, development and mental health of an entire generation.
On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.1 On March 13, 2020, the United States declared a national emergency.2 This was the first time such a declaration had been issued over an infectious disease outbreak since the 2009 H1N1 influenza pandemic. The declaration also instructed state governments to set up emergency operations centers, directed hospitals nationwide to activate emergency preparedness contingency plans and allowed health secretary Alex Azar to waive regulations that could hinder health professionals’ response capabilities. Soon after, states issued stay-at-home orders and schools began to close. Early in the pandemic, school closure was associated with decreased COVID-19 incidence and mortality. Those states that closed schools earlier had the largest relative reduction in incidence and mortality.3
Stay-at-Home Orders
Children with COVID-19 may be asymptomatic or only express mild symptoms that are indistinguishable from other common childhood respiratory tract infections. This presentation allows them to spread the virus more easily, as they are often feeling well. Studies have demonstrated an association between school closure and reduced transmission of viral respiratory illnesses.4 Due to these concerns, all states closed schools in mid-March 2020. The importance of school for child development, growth and overall well-being cannot be understated. While public health measures were very much needed, it was not without some unintended consequences. School closures only compound the economic, health and achievement inequities, disproportionately affecting disadvantaged children. Additionally, limited access to technology and school meals contributed to the widening disparities. There is no doubt that these public health measures were essential, but the social and economic impacts must also be understood.
Effects on Children’s Development
As social creatures, developing humans depend on social interaction beyond their immediate family in order to learn fundamentals, such as expressive and receptive language and how to behave in society.5 When these social and developmental supports are curtailed for prolonged periods, severe physical and mental health consequences in children are predicted to ensue.6,7 The consequences of isolation fall along a continuum for children contending with distance learning and sheltering in place. Thus, although we do not have data yet to trace the precise impact of the isolation caused by the COVID-19 pandemic on children’s development, it is reasonable to conclude that it will be significant.8
Psychological Consequences of the Pandemic
Considerable evidence already exists to demonstrate that humans respond to trauma, be they natural or manmade, in predictable ways.8 These ways are partly related to the stress response. The adverse psychological consequences of natural disasters, such as pandemics, are typically not observed in the immediate aftermath of the event. The response to a disaster can be positive, reflecting the adaptive nature of the stress response and our capacity for altruism and salutogenesis.9 Unfortunately, there are some longer-term consequences of the stress associated with natural disasters that can be devastating in their impact. These negative psychological consequences had mental health experts predicting that there would be surges not only in infections, but also in psychological distress/suffering associated with the protracted COVID-19 pandemic.7,10 Early evidence of this phenomenon was demonstrated in a Morbidity and Mortality World Report (MMWR) finding from the summer of 2020.11 In a web-based representative panel survey conducted in June 2020, adult participants were found to have reported increased rates of affective disorders, substance use disorders and suicidal ideation. Thus, the adversity of social isolation was already apparent in adults roughly three months after the nationwide shelter-in-place edict was imposed.
Different Age Groups Manifest Consequences Differently
Numerous observations of the impact of trauma on youth have demonstrated that the mostly negative responses to psychological stressors differ depending on the age of the child. Younger children can manifest behaviors that suggest that they have experienced disrupted attachment, can demonstrate deficits in cognitive and/or socioemotional development and can have regression of milestones (especially in toileting), clinginess and difficulty sleeping.8
Older children often express worries (about their safety or the safety of their caregivers), complain about physical symptoms like stomachache and headache and have academic difficulties (separate from those associated with distance learning). For many children, school is a safety net. Practically, schools can provide everything from subsidized meals to aftercare programs, peer support and the support of other caring adults in their lives. When schools close, children are abruptly cut off from these essential psychosocial and programmatic supports. Children exhibit the consequences of having suffered these losses through difficulty with emotional and physical regulation.6 Mental health clinicians have reported increased complaints of depressive symptoms including worsening social withdrawal (from peers and family) even when given the opportunity to interact in socially distanced or outdoor settings, changes in appetite and sleep and worsening apathy. For example, children who are struggling with depression and anxiety may begin to fully retreat from all familial interaction and exhibit decreased interest in activities that used to be enjoyable. These symptoms are all prototypical signs of neurovegetative depression, where depression begins to manifest in a patient’s body. The changes are physiological, not only in a patient’s moods and feelings. Some manifest this anxiety and fear behaviorally, throwing tantrums and being more defiant. Behavioral dysregulation occurs when routines like following the schedule of a school day are disrupted. Others are more fearful and clingier with their parents, not wanting to venture outside the home, possibly because they are afraid of being in a world without the sources of comfort and support they were previously able to depend on.
Children with special needs and their parents rely on public schools to provide speech, occupational and physical therapy as well as teachers who are specialized in providing emotional and educational support. When schools closed, access to these specialized resources effectively vanished and could not be replicated through virtual care. In theory, community clinics could have filled the gap and provided virtual resources, but they are not necessarily free nor were they as readily available as public schools, especially as demand increased. Many children with special needs require their interactions to be scaffolded by a trained therapist, and this training could not be effectively taught online to caregivers (who were then expected to be the proxy therapists), nor were many families in the financial position to provide full-time support. While schools remained closed, children with special needs and their families were uniquely disadvantaged.
Adolescents and transitional-age youth as a group also experienced severe consequences, a finding predicted from previous observations.12 Adolescents suffering from the impact of trauma can become more socially isolated, experience worsening irritability or sense of guilt and engage in hostile acts toward themselves and others (such as deliberate or subconscious self-destructive behavior or increased rates of gun violence, respectively), express thoughts of suicide and demonstrate these thoughts through self-harm behaviors such as cutting. Disordered eating is another behavioral manifestation of adolescent distress, a mechanism implemented to help manage difficult feelings. While some youth restricted their food intake in order to gain a sense of control over their environment, some youth were restricting their nutritional intake to consciously sacrifice their own nourishment in the hopes that the rest of their family could eat when they no longer received schoolsubsidized meals.12 Others followed an established pattern of overconsuming hyperpalatable food and gaining excessive weight. Additionally, they missed the important milestones of their academic careers (graduations, sporting events, prom) and had to mourn the losses of quintessential high school events that they were not able to experience. The preliminary evidence regarding the psychological distress of adults during the COVID-19 pandemic was already dire, and then another report confirmed what was anticipated from the data summarized above. In a report on mental health-related emergency department visits of youth between January and October 2020, Leeb and colleagues13 revealed that there was a proportional increase over the numbers from the same month one year prior. They also found that adolescents were more impacted (31% increase) than children (24%).
Impact of COVID Is Not Homogenous
When summarizing the effect of the COVID-19 pandemic on children’s development, we can sort the outcome into three categories: those who survive, those who strive and those who thrive. The majority of youth who experienced the pandemic were able to manage the discomfort of their trauma adequately and survive the struggle, especially when they had family support. Those children who already suffered with depression or anxiety or who had moderate/severe neurodevelopmental disorders had to strive to endure the pandemic with amplified symptoms. It should be noted that not every child was able to access the standard mental health services that they needed during this difficult time. They had to turn to ancillary support services, like their pediatric clinics, or they had to suffer alone, leading to the ER visits documented by Leeb and colleagues.13 Remarkably, for all of the recognition of the negative outcomes of the pandemic on children’s development, a subset of youth was actually able to thrive. These children were likely able to fare reasonably well because their preexisting conditions could be ameliorated by distance, namely social distancing and distance learning. Routine dental exams may be the first time children venture out of their homes.
Effects on Pediatric Dentistry
The practice of dentistry has adapted to the new COVID-19 environment. This holds true for not only the practice of dentistry but for dental education as well. Guidelines for personal protective equipment and environmental infection control in health care facilities have long existed, but these were used for patients with a confirmed infection transmitted through secretions from the respiratory tract, such as Mycobacterium tuberculosis.14 The need for emergent dental treatment in these patients with an active infection was rare and a hospital setting was indicated. However, due to the asymptomatic nature of COVID-19 in early stages and the lack of information about transmission during this period, dental offices have been required to treat all patients as potentially infectious.15 Thus, dentists had to navigate a patchwork of COVID-19 guidelines issued by different agencies to replicate hospital settings in dental offices that were not designed for that purpose.16 Guidelines have recommended a litany of changes such as delay of nonemergent procedures based on the local environment, teledentistry, preprocedural screening of patients for symptoms, room rest time before cleaning, limitation of visitors, use of face masks, use of physical barriers, removal of shared items in the waiting room, use of four-handed dentistry, use of rubber dam, alternatives to aerosol, use of high-volume suction, preprocedural mouthwashes, N-95 respirators or equivalent devices for aerosol-generating procedures, use of individual patient rooms and use of HEPA filtration to supplement air turnover times.17 Dentists were asked to monitor themselves for symptoms and to implement flexible leave policies for staff, which was a challenge prior to the pandemic18 and even more difficult during a period when small businesses were facing financial catastrophe.
Pediatric dentists have had to navigate additional complexities. While there was guidance on management of aerosolgenerating procedures, these guidelines failed to address bioaerosols produced during difficult patient behaviors such as forceful crying, spitting and coughing.19 Guidelines stated that visitors to the office should be limited, but individual dentists were forced to decide when children could be separated from their caregivers and subsequently manage the repercussions of these decisions.19 Early in the pandemic, when pediatric dentists were managing emergencies with no access to general anesthesia, guidance on the safety of nitrous oxideoxygen inhalation sedation was lacking.20 Finally, children and adults with special health care needs who need access to general anesthesia have been impacted by changes resulting in reduced access. Prior to the pandemic, pediatric dentists were already struggling to access operating rooms for dental treatment.21 With competition from medical specialties, general anesthesia resources are scarcer and the specter of infection transmission due to aerosol-generating dental procedures may be an additional pretext for cutting these low-reimbursement procedures.21 As a result, dental care in the pandemic presented unique challenges for dentistry for children.
As the pandemic continues, it is unclear how the interim guidance for infection control17 will evolve or potentially become permanent. Infectivity for dentists remains below 1% with no identified cases of transmission in the dental office.22 Likely, these results are evidence that infection control practices have been successful but further studies are needed regarding the role of aerosols in dentistry in infectious disease transmission.23 Currently, no guidance suggests what level of community spread will be adequate to relax these interim guidelines. Current advice to dentist is that, despite full vaccination, dentists should continue to follow CDC guidance.24 With many predicting that COVID-19 is only the first of a future of similar pandemics, one may conjecture that these emergency measures will be activated more rapidly in the future or that this is the new normal level of prevention.
In addition to infection control measures, other recommendations have suggested a fundamental shift in the practice of dentistry. Namely, delay of nonemergent procedures, use of teledentistry as an alternative to traditional care and avoiding aerosolgenerating procedures when possible. Early in the pandemic when many offices faced restrictions on elective procedures, dentists had to define the term elective care. Emergency care was defined as swelling that restricts swallowing and extends to the eye, uncontrolled bleeding or facial trauma.25 However, classification of urgent cases was more challenging and dependent on patient-specific circumstances (ADA guidance emergency). Worldwide, health care utilization has decreased by one-third during the pandemic.26 Preliminary reports suggested that nearly half (46.7%) of U.S. adults had delayed going to the dentist, with 12.4% delaying care to address a specific problem.27 This reduction is likely still present, as the most currently available practice patterns suggest that 61.2% of pediatric dentists are seeing lower patient volume than usual, according to the ADA Health Policy Institute (HPI). The impact of this deferral of care is yet to be determined, but anecdotal experiences show that it has resulted in more severe disease. More concerningly, the perception that dental care is a danger that can safely be delayed has led to deferral of care until it reached emergency status. If this concept of deferred care becomes the norm, pediatric dentistry could revert to symptom-driven care-seeking in conflict with the dental home concept. The dental profession should use this opportunity to construct an evidence-based framework for deferral of care that accounts for an extended duration emergency such as COVID-19.
Teledentistry and the broader umbrella of telemedicine was lauded as a way to allow optimal triage and ongoing medical care during the pandemic.28 Teledentistry specifically has been used for limited evaluations and triage and to continue ongoing preventive care.29 Data on practice patterns from an ADA HPI survey show that pediatric dentists are most likely to be using virtual technologies or telecommunications compared to the other specialties and are primarily using them to triage emergencies and for post-ops. Although third-party payers and regulatory bodies eventually implemented flexibility to permit and cover these services, there is no certainty that teledentistry funding will become permanent. If these frameworks are effectively dismantled, dental offices may be forced to provide some of these services necessary for appropriate triage with no reimbursement. Without this infrastructure in place, precious time could be lost in a new pandemic and leave dental providers less likely to invest in this teledentistry in the future.
As the CDC has recommended avoiding aerosol-generating procedures and prioritizing minimally invasive/ atraumatic restorative techniques (use of hand instruments only), recommendations specific to pediatric dentistry were to use approaches such as Hall technique crowns, silver diamine fluoride and/ or interim therapeutic restorations.15 A shift toward noninvasive procedures in a biological approach to carious lesions was already underway in pediatric dentistry and COVID-19 has only catalyzed this transition.30 The pandemic provides the opportunity to study these approaches indepth. However, it should not be used as an excuse to entirely shift from traditional approaches to pediatric dentistry and for third parties to pressure dentists to use the “least expensive treatment” audit benchmark as a substitute for clinical judgement.31 Wholesale implementation without rigorous trials may place children dependent on public funding at risk for a separate tier of care than their private-pay counterparts.
Hope for the Future: COVID-19 Vaccine for Children
Rapid development of an efficacious and safe vaccine against COVID-19 began early in the pandemic. Following the identification of the genetic sequence of COVID-19, the rapid emergence of research and collaboration among scientists and biopharmaceutical manufacturers has been unprecedented.
As of September 2021, the PfizerBioNTech vaccine was the only vaccine with full approval from the U.S. Food and Drug Administration for people over 16 years of age and authorized for emergency use (EUA) for those 12–15 years old. Vaccines developed by Moderna and J&J/Janssen are also approved under the emergency use authorization.32 Pfizer-BioNTech vaccine developed in the U.S. and reported to be 95% effective in those over age 16 and 100% effective in those aged 12-15 The Moderna vaccine was 94.1% effective at preventing laboratory-confirmed COVID-19 illness in people who received two doses who had no evidence of being previously infected. Both PfizerBioNTech and Moderna vaccines require two shots. The third vaccine, the J&J/ Janssen vaccine, is recommended for people aged 18 and older and was 66.3% effective in clinical trials.
There is a race currently between getting the population vaccinated and reducing transmission and mortality. It is estimated that nearly 75% of the population needs to gain immunity by either developing antibodies or vaccinations. As of July 2021, nearly half (49.4%) of the U.S. population was fully vaccinated, so the goal of 75% or higher is an achievable goal.33 Among children ages 12 to 18, nearly 60% were fully vaccinated. This holds promise for the upcoming school year.
The COVID-19 pandemic will have lasting impact on society and its children. As we begin to reemerge from the pandemic, we must be prepared to address not only the physical but also the emotional, psychological and developmental impacts it has had on children.
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THE CORRESPONDING AUTHOR, Jessica Y. Lee DDS, MPH, PhD, can be reached at jessica_lee@unc.edu.
