For the past three months, Coloradans have been told to avoid leaving their homes as much as possible. The message appeared largely well-heeded, likely saving lives, but it also resulted in a decrease in parents bringing children to routine and even emergency health care.
Denver-area hospitals saw a 30 to 50 percent drop in emergency room visits in April, according to Rocky Mountain Hospital for Children. Member clinics of Colorado Community Health Network, which report serving more than one in seven Coloradans, are at 75 percent or below prior visit volume, even including telehealth appointments.
News of overwhelmed medical systems and limited resources for personal protective equipment contributed to fear and uncertainty. Many providers converted to various degrees of telehealth appointments, carved out times they would see well and symptomatic patients, and some underwent temporary complete closures. Record high unemployment in Colorado meant changes in health coverage and, for many, inability to pay.
However countercurrent it may sound, it could be time to mask up and make that appointment for the well-being of your child.
Safe and Consistent Care for Children
The American Academy of Pediatrics released a report on May 8 guiding pediatricians in providing safe and consistent care for children during the pandemic.
“Since the onset of the pandemic, a significant drop in well-child visits has resulted in delays in vaccinations, delays in appropriate screenings and referrals, and delays in anticipatory guidance to assure optimal health,” said the release.
The AAP advises well-child appointments occur in person whenever possible—with sanitization and patient distancing measures—for the good of the child’s continuity of care. Telehealth may be an appropriate piece of an exam, but should include a timely in-person follow up. Immunization schedules are also key considerations—particularly for Colorado as the state with the lowest rate of kindergarten measles, mumps, and rubella vaccinations.
A large number of Colorado primary care offices and hospitals are acting on these guidelines already, according to Dr. David Brumbaugh, associate chief medical officer for Children’s Hospital Colorado.
“I think all are safe places to be right now,” he says. “The alignment with Children’s and our entire group of referring pediatricians has never been stronger in the sense of having weekly conversations about what we should be doing as a pediatric community in terms of keeping families safe.”
Adapting Medical Environments
Dr. Terez Malka, a pediatric emergency medicine physician who works at emergency rooms around the state including at Rocky Mountain Hospital for Children, points out that many health facilities are better at understanding the dynamics of the coronavirus and have adapted their environments to ensure safety.
Some clinics and primary care offices have designated half their business days to do preventative appointments and the other half for patients with symptoms. Many practitioners are doing initial assessments at the front door or even doing temperature and symptom checks with families in the parking lots before they enter. Children’s Hospital Colorado requires masks for all patients and visitors over the age of two, offers parents testing to make sure they’re safe to visit their children, and posts signage promoting physical distancing and elevator limits.
Confidence to Get Back on Schedule
Understanding the details about patient safety helped Laura-Anne Cleveland decide to resume her kids’ in-person medical appointments. Cleveland, an associate chief nursing officer for Rocky Mountain Hospital for Children in Denver, delayed her five kids’ annual well-child checks for months because she’d assumed primary care offices were closed and was unsure about medical settings outside the hospital.
“The challenging thing that we saw within the hospitals is that there were so many unknowns about coronavirus,” she says. “So I knew that [Rocky Mountain Hospital for Children] were doing things right. But are other facilities doing things right? That definitely made me more cautious to doing any type of doctor’s appointments.”
Cleveland hadn’t wanted to take her kids in unless there was a dire need. Thankfully, they haven’t had to visit the ER. But it’s about time her daughter’s asthma medicine gets adjusted, and her son has been showing signs of hearing loss possibly related to his special needs. Speaking with her kids’ medical teams about their appointment availability and public health measures led her to start putting preventative care and specialist visits on the calendar.
Recognizing Serious Symptoms
Delaying care often results in common problems becoming more complicated. More than the typical cases of ruptured appendicitis, for example, have been reported at Colorado hospitals. Dr. Malka says cases of ear infections, strep throat, and broken bones have been missed or treated only once patients came in with more complications. Parents are urged to recognize their child’s symptoms and get in touch with a doctor in the case of illness or emergency.
“I think a reputable telemedicine source is great,” says Dr. Malka. “Pediatricians will do phone visits, ERs have a nurse line. Google medicine can be really variable. A lot of childhood illnesses will get better on their own with just Tylenol and ibuprofen and that’s wonderful, but what we’re trained to do as physicians is figure out the difference between that minor illness that’s gonna be fine at home, and what is actually a sign of something more serious.”
Something like the multisystem inflammatory syndrome in children (MIS-C) that has reported links to the coronavirus and four cases so far in Colorado. In the early stages, says Malka, MIS-C can look like a normal virus, but then turn serious.
The Benefits of Accessible Telehealth
Some initial concerns may be addressed in telehealth visits, which have been in greater use and availability. The convenience and safety are also particularly important for patients with lower incomes, says Polly Anderson, vice president of strategy and financing at Colorado Community Health Network, which is a membership of 20 centers with more than 200 sites serving patients who are mostly uninsured or on Medicaid.
“Health center patients by design and target are low-income, uninsured, Medicaid,” says Anderson. “Most patients are below 200 percent of the federal poverty level. These are folks who work multiple jobs, may work long hours, may only have one car per family, and so getting to appointments is difficult. This is really rapidly changing our healthcare system, and lots of folks will want the care via telemedicine beyond the outbreak as well. We’re hopeful for that as a way to expand access to primary care.”
Some Things Require In-Person Care
Primary and preventative care visits are opportunities for important developmental measurements such as growth or hearing and sight strength. Providers can also screen for child abuse and food insecurity, help manage chronic conditions, and offer resources for social and emotional health. Parents can speak with their regular providers or health centers about the risks and opportunities of an in-person visit. If a child is due for immunizations, that’s a major reason to go in.
Cleveland says she values her children’s regular health care appointments. She currently relies on telehealth for psychiatry and behavioral health and specialists for her three children with special needs. She’s glad to get all five of them back in their pediatrician’s office to assess their rapid physical growth and stages of maturity.
“He knows my kids the best, he’s seen them from birth on,” says Cleveland. “It’s really comforting to know that he’s going to check them over in the areas that I may miss and make sure that they’re growing appropriately.”
She’s also excited, likely much more so than her kids, about keeping up on vaccinations and getting ready for the school year—whatever that may look like this fall.
Parents can monitor the CDC’s collection of information about COVID-19 and pediatrics here.
