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Table of Contents    
LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 4  |  Page : 952-954

COVID-19 and Child Neurology Care


1 Center of Excellence and Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
2 Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication26-Aug-2020

Correspondence Address:
Dr. Sheffali Gulati
Center of Excellence and Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.293484

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How to cite this article:
Gulati S, Gupta J, Madaan P. COVID-19 and Child Neurology Care. Neurol India 2020;68:952-4

How to cite this URL:
Gulati S, Gupta J, Madaan P. COVID-19 and Child Neurology Care. Neurol India [serial online] 2020 [cited 2020 Oct 20];68:952-4. Available from: https://www.neurologyindia.com/text.asp?2020/68/4/952/293484




Sir,

The escalating pandemic of coronavirus disease 2019 (COVID-19) has posed a multitude of challenges for pediatric neurologists. These range from managing children with COVID-19 presenting with neurological involvement to diagnosing COVID-19 in children presenting with isolated neurological manifestations and providing a continuum of care to children with pre-existing or newly diagnosed neurological disorders during this difficult time.

The spectrum of neurological manifestations of COVID-19 continues to evolve with identification and reporting of various neurological symptoms, more commonly in adults as compared to children. Some of the common reported neurological manifestations pertaining to central nervous system in adults are dizziness, headache, encephalopathy, cerebro-vascular events, olfactory and gustatory dysfunction.[1] The peripheral nervous system manifestations described are Guillain-Barre syndrome and its variants and skeletal muscle injury.[1],[2]


  Neurological Manifestations Associated With Covid-19 in Children Top


Neurological manifestations associated with COVID-19 in children are rare and limited to a few case reports/series. These case reports illustrate acute symptomatic seizures, new-onset status epilepticus (secondary to probable encephalitis) in an 11 year-old, ischemic stroke (secondary to focal cerebral arteriopathy) in a 12 year-old and brief encephalopathy in a case series of 4 infants.[3],[4],[5],[6] Strikingly all these children had a favorable outcome (except the child with stroke who required rehabilitation for hemiparesis).


  Children With Disabilities Top


The prevalence of neuro-developmental disorders (NDD) in children (2 to 9 years of age) is as high as 12% (>21% of whom had >1 NDD) in our country and NDDs are the principal cause of disability in children.[7] Even prior to this pandemic, their unmet needs were huge. Lockdown and closed or limited OPD services have just heightened the rehabilitation needs of disabled children. This gap is even wider for children requiring face-to-face tailored sessions such as physical therapy for those with cerebral palsy, neuromuscular disorders, etc. and behavioral therapy for those with neuro-developmental disorders.

This calls for a multidisciplinary co-operation to initiate rehabilitation guidance on teleconsultation by clinicians, physiotherapists, occupational therapists and child psychologists (both for physical and behavioral therapy advice using video call when necessary). This should be supplemented with the use of assistive communication aids to facilitate for children with co-morbidities like vision and hearing impairment.[8] Children and adolescents with intellectual disability have limited understanding of the concept of pandemic and its preventive measures. Therefore, the public health messages such as repeated washing hands, social distancing, etc. should be disability-inclusive with use of pictures, simple language, cartoons/education comic for children.[9] A standstill of public transportation services has further led to problems with healthcare access especially for children with disabilities. Since COVID-19 is likely to be around for a long time, disabled friendly measures are the need of the hour.


  Children With Pre-Existing/newly Diagnosed Neurological Disorders Top


The general preventive measures of social distancing, limiting exposure to crowded places, use of well-fitted masks in public places and cough etiquettes should be re-enforced in children with neurological disorders, especially in those on immunomodulatory therapies. There are concerns about initiating and continuing immuno-modulatory treatments in children with various pre-existing or newly diagnosed neurological disorders which may also mean increased hospital visits. To address the above concerns, the latest recommendations for various disorders pertaining to Indian context have been compiled in [Table 1].
Table 1: Recommendations for children with pre-existing/newly diagnosed neurological disorders

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Broadly children who are already on steroids (e.g., Duchenne's muscular dystrophy (DMD), demyelinating disorders, autoimmune encephalitis, etc.) should continue their doses as prescribed, which should be converted to stress dose during acute illness. Children with DMD should continue to take ACE (angiotensin-converting enzyme) inhibitors.[10] Children who are already on azathioprine or mycophenolate mofetil for maintenance immune-suppression should continue in consideration for risks and benefits with close monitoring for lymphopenia and hepatotoxicity. However, initiating rituximab/azathioprine/mycophenolate mofetil may be delayed based on clinician's judgement.[11] Clinicians treating children with infantile spasms should choose amongst adrenocorticotrophic hormone, high-dose prednisolone, and vigabatrin avoiding non-standard therapies such as topiramate, ketogenic diet as the first line drugs.[12]

The latest recommendations on children with spinal muscular atrophy (SMA) emphasize the need to restore therapies like nusinersen and onasemnogene abeparvovec-xioi which are life-altering treatments for this progressive disease. This can be achieved by inter-departmental collaboration in discussion with caregivers as it will require exposure to health-care facilities, caring for a immunosuppressed child and regular lab monitoring post therapy.[16]

To conclude, use of teleconsultation is strongly encouraged as far as possible to address pediatric neurology consultations, however for those children who land up in emergency room, the importance of donning appropriate personal protective equipment (PPE) by the examining neurologist cannot be overemphasized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77:1-9.  Back to cited text no. 1
    
2.
Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: Causality or coincidence? Lancet Neurol 2020;19:383-4.  Back to cited text no. 2
    
3.
Nathan N, Prevost B, Corvol H. Atypical presentation of COVID-19 in young infants. Lancet 2020;395:1481.  Back to cited text no. 3
    
4.
Chacón-Aguilar R, Osorio-Cámara JM, Sanjurjo-Jimenez I, González-González C, López-Carnero J, Pérez-Moneo-Agapito B. COVID-19: Fever syndrome and neurological symptoms in a neonate. An Pediatr (Engl Ed) 2020;92:373-4.  Back to cited text no. 4
    
5.
McAbee GN, Brosgol Y, Pavlakis S, Agha R, Gaffoor M. Encephalitis associated with COVID-19 infection in an 11 year-old child. Pediatr Neurol 2020;S0887899420301430. doi: 10.1016/j.pediatrneurol.2020.04.013.  Back to cited text no. 5
    
6.
Dugue R, Cay-Martínez KC, Thakur K, Garcia JA, Chauhan LV, Williams SH, et al. Neurologic manifestations in an infant with COVID-19. Neurology 2020;94:1100-2.  Back to cited text no. 6
    
7.
Arora NK, Nair MKC, Gulati S, Deshmukh V, Mohapatra A, Mishra D, et al. Neurodevelopmental disorders in children aged 2–9 years: Population-based burden estimates across five regions in India. PLoS Med 2018;15:e1002615.  Back to cited text no. 7
    
8.
Gupta J, Madaan P, Gulati S. COVID-19: Implications for Children with Special Needs. JRTDD2020 5;3:1-3.  Back to cited text no. 8
    
9.
Armitage R, Nellums LB. The COVID-19 response must be disability inclusive. Lancet Public Health 2020;5:e257.  Back to cited text no. 9
    
10.
Veerapandiyan A, Wagner KR, Apkon S, McDonald CM, Mathews KD, Parsons JA, et al. The care of patients with Duchenne, Becker, and other muscular dystrophies in the COVID-19 pandemic. Muscle Nerve 2020;62:41-5.  Back to cited text no. 10
    
11.
Manji H, Carr AS, Brownlee WJ, Lunn MP. Neurology in the time of COVID-19. J Neurol Neurosurg Psychiatry 2020;91:568-70.  Back to cited text no. 11
    
12.
Child neurology society statement for release_Management of Infantile spasms (IS) during COVID-19 pandemic. April 2020 [Internet]. Available from: https://www.childneurologysociety.org/docs/default-source/2020-cns-/cns-statement-for-release_management-of-infantile-spasms-during-the-covid19-pandemic-(4-6-20).pdf?sfvrsn=435065b8_2. [Last cited on 2020 May 15].  Back to cited text no. 12
    
13.
Jacob S, Muppidi S, Guidon A, Guptill J, Hehir M, Howard JF, et al. Guidance for the management of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) during the COVID-19 pandemic. J Neurol Sci 2020;412:116803.  Back to cited text no. 13
    
14.
French JA, Brodie MJ, Caraballo R, Devinsky O, Ding D, Jehi L, et al. Keeping people with epilepsy safe during the COVID-19 pandemic. Neurology 2020;94:1032-7.  Back to cited text no. 14
    
15.
Leira EC, Russman AN, Biller J, Brown DL, Bushnell CD, Caso V, et al. Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions. Neurology 2020. doi: 10.1212/WNL.0000000000009713.  Back to cited text no. 15
    
16.
Veerapandiyan A, Connolly AM, Finkel RS, Arya K, Mathews KD, Smith EC, et al. Spinal muscular atrophy care in the COVID-19 pandemic era. Muscle Nerve 2020;62:46-9.  Back to cited text no. 16
    



 
 
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