Pediatric Endoscopy in the Era of Coronavirus Disease 2019: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper

Mobile health technology in pediatric EGD quality indicators assessment: results from a national program of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIMS

Upper endoscopy (UE) procedures (EGD and ERCP) are an established standard of care in pediatric gastroenterology. The Pediatric Endoscopy Quality Improvement Network (PEnQuIN) recently published its pediatric-specific endoscopy quality guidelines. This study, initiated by the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition, aims to evaluate the adherence of Italian pediatric endoscopy centers (PECs) to these established quality standards.

METHODS

Conducted between April 2019 and March 2021, this nationwide study used a smartphone-based app approach. Data encompassing pediatric endoscopy facilities, patient profiles, endoscopy indications, 17 procedure-related PEnQuIN indicators, and a patient satisfaction questionnaire (Group Health Association of America-9) were systematically collected.

RESULTS

A comprehensive analysis of 3582 procedures from 24 centers revealed that 2654 (76%) were UEs. The majority of centers (75%) involved >1 operator, with 9 centers incorporating adult endoscopists, responsible for 5% of UEs. Overall, adherence to quality standards was good; however, areas of improvement include suboptimal reporting of sedation details, adherence to disease-specific guidelines, and patient satisfaction questionnaire completeness (56%). The adverse event rate aligned with literature standards (1%), and patient satisfaction was generally high. A noteworthy observation was a 30% decreased monthly reporting rate and a shift in disease-specific patterns after the COVID-19 outbreak.

CONCLUSIONS

Pediatric UE practices in Italy adhere well to established quality standards. Emphasizing the adoption of disease-specific guidelines is crucial for optimizing resources, enhancing diagnostic accuracy, and minimizing unnecessary procedures. Prioritizing patient satisfaction is important for immediate enhancements in practice as well as for future research endeavors.

Pediatric endoscopy in times of pandemic: A nationwide retrospective analysis

BACKGROUND

Gastrointestinal endoscopy is a procedure that carries an increased risk of transmission of SARS-CoV-2 infection to medical staff. In patients, COVID-19 is a risk factor for adverse events of medical procedures. This study analyzed the real-life risk of, and factors contributing to, infection transmission to endoscopic personnel, and possible adverse events of the endoscopy procedure and anesthesia in children with COVID-19.

METHODS

Nationwide retrospective analysis of medical records of children with confirmed SARS-CoV-2 infection who underwent gastrointestinal endoscopy in Poland between February 2020 and February 2022.

RESULTS

Fifty-eight patients were included in the analysis, 35% of whom had COVID-19 symptoms at the time of endoscopy. The dominant indications for endoscopy were foreign body or corrosive substance ingestion and gastrointestinal bleeding. Nine cases of virus transmission were registered among endoscopic personnel. In all of these cases, the endoscopy team was unaware of the patient's infection (p < 0.01), although symptoms were present in 78% of the children. Lack of use of personal protective equipment was the strongest predictor of SARS-CoV-2 transmission (p < 0.01). The risk of infection was not statistically significantly dependent on the method of anesthesia, intubation or the type of endoscopy. No statistically significant correlation was found between symptomatic infection and adverse events of endoscopy or anesthesia occurrence. There was one reported anesthesia-related adverse event involving extubation difficulties due to worsening respiratory infection symptoms.

CONCLUSIONS

The risk of transmitting SARS-CoV-2 to endoscopic personnel during procedures in children is low and depends on compliance with infection prevention and control measures. Performing gastrointestinal endoscopy in children with COVID-19 does not appear to be associated with an increased risk of adverse events.

COVID-19 positive cases in a pediatric surgery department from Romania: Case series from 2 years of pandemics

RATIONALE

The COVID-19 pandemic had a dramatic effect on various health systems in terms of admissions and outcomes, including pediatric surgery activity. The aim of this paper was to analyze the outcome of SARS-CoV-2-positive patients admitted to our department during the regional COVID-19 pandemic in North-Eastern Romania. We also evaluated the changes generated in our daily practice by the COVID-19 pandemic and the dynamic response to this major challenge.

PATIENT CONCERNS

The patients presented with symptoms related to their primary diagnosis: local pain and deformity in case of fractures; pain, swelling, and erythema in case of abscess; pain and decreased range of motion (ROM) in case of intolerance to metal implants. Other specific concerns are mentioned on an individual basis.

DIAGNOSES

Eighteen patients (of which 4 had acute appendicitis and were included in a previous article), representing 1.18% of the total number of admissions, tested positive for SARS-CoV-2. There were 4 patients with fractures, 3 patients with soft tissue abscess or cellulitis, 2 patients with intolerance to metal implants, 1 patient with facial burn, 1 patient with thumb laceration, 1 patient with liver trauma, 1 patient with undescende testis, and 1 patient with symptomatic inguinal hernia, respectively. Boys represented 11/ 14 (78.57%) of the cases. The mean age of the patients was 9 years 11 months. There were only mild COVID-19 cases.

INTERVENTIONS

Surgery was performed in 13/ 14 (95.71%) of cases. The fractures were treated with open reduction internal fixation (ORIF); incision and drainage (I & D) were performed in case of soft tissue abscess; the metal implants were removed in case of local intolerance. Other conditions (burn, inguinal hernia, undescended testis, skin laceration) were treated specifically. Only 1 patient with liver laceration was treated conservatively under close hemodynamic monitoring.

OUTCOMES

The mean length of stay (LoS) was 2.71 days. The infection with the SARS-CoV-2 virus had no deleterious effect on the surgical outcome among the 14 patients included in the study. There were no surgical complications during admission and no patient returned for late complications related to their primary disease or SARS-CoV-2 infection.

LESSONS

The SARS-CoV-2 infection had no significant influence on the outcome of pediatric surgical cases included in the study. We noticed a significant (31.54%) decrease in the number of admissions compared to the previous 2-year interval before the COVID-19 pandemic. Fast and adequate adjustment of the daily activity imposed by the COVID-19 pandemic was feasible and may be used in the future should similar epidemiological emergencies occur.

Impact of the Coronavirus Disease 2019 Pandemic on Pediatric Gastrointestinal Endoscopy: A Questionnaire-based Internet Survey of 162 Institutional Experiences in Asia Pacific

Purpose

The impact of coronavirus 2019 (COVID-19) on gastrointestinal (GI) endoscopy procedures in adults has been reported, with a drastic reduction in the number of procedures. However, there are no sufficient data regarding the impact on pediatric GI endoscopy. Here, we aimed to report that impact in the Asia-Pacific region.

Methods

A questionnaire-based internet survey was conducted from June to November 2021 among pediatric endoscopy institutions in the Asia-Pacific region, with each institution providing a single response. Overall, 25 questions focused on the impact of the number of procedures conducted, the usage of personal protective equipment (PPE), and endoscopy training programs during the pandemic.

Results

A total of 162 institutions across 13 countries in the Asia-Pacific region participated in the study, and 133 (82.1%) institutions underwent procedure changes since the emergence of COVID-19. The number of esophagogastroduodenoscopy and ileocolonoscopy procedures decreased in 118/133 (88.7%) and 112/133 (84.2%) institutions, respectively. Endoscopy for patient with positive COVID-19 in an emergency or urgent cases still carried out in 102/162 (62.9%) institutions. Screening of COVID-19 for all patients before endoscopy was done across 110/162 (67.9%) institutions. PPE recommendations varied among institutions. Pediatric gastrointestinal endoscopy training programs were discontinued in 127/162 (78.4%) institutions.

Conclusion

This study reports the impact of the COVID-19 pandemic on pediatric gastrointestinal endoscopy in the Asia-Pacific region. There has been a significant reduction in the number of endoscopic procedures and relevant training programs.

Impact of Telemedicine on Delivery of Pediatric Inflammatory Bowel Disease Care

OBJECTIVES

Outpatient inflammatory bowel disease (IBD) care shifted from office visits (OVs) to a model with integrated telemedicine during the 2020 COVID-19 pandemic. We describe the impact of this shift on delivery of pediatric IBD care.

METHODS

We collected electronic medical record data from office and telemedicine visits for pediatric patients with IBD at a single center from April 2019 to December 2020. We compared visit volume, duration, and test ordering between 2019 and 2020, and between OV and telemedicine, and assessed for differences in telemedicine adoption by sociodemographic factors.

RESULTS

Visit volume was maintained between 2019 and 2020. Median overall appointment time was shorter for telemedicine versus OV [46 (interquartile range, IQR 35-72) vs 62 (IQR 51-80) minutes; P < 0.001] with no significant difference in time spent with provider [28 (IQR 21-41) vs OV 30 (IQR 24-39) minutes; P = 0.08]. Accounting for drive time, telemedicine visits were 2.6 times shorter than office visits in 2020 ( P < 0.001). In univariate analyses, there was no difference in telemedicine utilization by race or gender. Variables significantly associated with telemedicine were older age, English as primary language, being non-Hispanic, commercial insurance, living in an area of very high opportunity, and having a longer drive time to the office ( P < 0.05 for all comparisons). In multivariate analyses, visits among patients with commercial insurance were significantly more likely to be conducted via telemedicine ( P = 0.02). Among those with a telemedicine visit, multivariate analyses demonstrated multiracial patients were significantly more likely to have video visits (vs audio-only; P = 0.02), while patients with public insurance, no or missing insurance, and whose primary language was Arabic were significantly less likely to have video visits ( P < 0.05 for all comparisons).

CONCLUSIONS

Integrated telemedicine allowed for continued delivery of pediatric IBD care and significantly decreased appointment time. While telemedicine may improve access for those who live further from the office, concerns remain about the introduction of disparities.

Foreign body ingestion trends in children in the Daegu-Kyungpook Province, Korea before and during the COVID-19 period: a repeated cross-sectional study

Background

During the coronavirus disease 2019 (COVID-19) period, children spent more time at home, which is where most foreign body ingestions (FBIs) in children occur. We compared the rate of FBI in children in the Daegu-Kyungpook Province during COVID-19 to the rate in the 2 years before the COVID-19 period.

Methods

The period from January to December in the year 2020 was defined as the COVID-19 period, and the corresponding time period in 2018 and 2019 was defined as the pre-COVID-19 period. Medical records were analyzed retrospectively for pediatric patients aged 0-15 years who visited outpatient and emergency rooms at seven tertiary referral hospitals in Daegu-Kyungpook Province.

Results

The annual occurrence rate of FBIs in patients visiting seven tertiary referral hospitals was not different during COVID-19 compared to that in the pre-COVID-19 period and the median age of these patients during the COVID-19 and pre-COVID-19 periods was similar. However, occurrence rates increased in the groups aged 0-3 and 4-6 years but decreased in the group aged 7-15 years during the COVID-19 period. The proportion of male patients as well as inpatients increased significantly during the COVID-19 period (both P=0.01). The proportion of foreign bodies located in the post-pyloric region increased during the COVID-19 period (P=0.02). The most common symptom, foreign body sensation in the neck, was similar in both groups. There was no significant difference in the foreign body removal method between the two groups. The occurrence rates of swallowing of toys, coins, magnets, button batteries, and superabsorbent polymers non-significantly increased; and the food ingestion rate decreased, while the non-food ingestion rate increased in all age groups during the COVID-19 period.

Conclusions

The FBI rate in children did not differ during the COVID-19 period compared to that in the pre-COVID-19 period. The occurrence of FBI in boys, the number of foreign bodies located in the post-pyloric region, and the number of hospitalizations due to FBI increased during the COVID-19 period.

The Changes in Trends of Lower Gastrointestinal Endoscopy Conducted in Children and Adolescents after the COVID-19 Outbreak in Korea

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has affected medical practice in diverse ways. We aimed to investigate the change in trends of lower gastrointestinal (LGI) endoscopy conducted in children and adolescents after the COVID-19 outbreak in Korea. Material and Methods: This was a multicenter, retrospective study conducted in Korea. We included children and adolescents aged <19 years who had undergone their first LGI endoscopy between 2016 and 2020. We compared clinicodemographic and endoscopic factors between groups divided according to the pre- and postCOVID-19 era in Korea. Results: We included 1307 patients in this study. Colonoscopies, instead of sigmoidoscopies, were conducted in most patients in the postCOVID-19 era compared to those in the preCOVID-19 era (86.9% vs. 78.5%, p = 0.007). The diagnosis of inflammatory bowel disease (IBD) was also significantly higher in the postCOVID-19 era compared to the preCOVID-19 era (47.2% vs. 28.5%, p < 0.001). According to multivariate logistic regression analysis, age at LGI endoscopy, LGI bleeding indication, and IBD diagnosis were independently associated with the use of a colonoscopy over a sigmoidoscopy (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.12−1.27, p < 0.001; OR 0.56, 95% CI 0.37−0.83, p = 0.005; OR 1.80, 95% CI 1.20−2.77, p = 0.006, respectively). Conclusions: The COVID-19 pandemic has changed LGI endoscopy practice trends of pediatric gastroenterologists in Korea, who tended to perform lesser LGI endoscopies compared to previous years while conducting significantly more colonoscopies than sigmoidoscopies in the postCOVID-19 era. Furthermore, these colonoscopies were significantly associated with the diagnosis of IBD, as well as a significant increase in IBD diagnosis in the postCOVID-19 era.

Twelve Months with COVID-19: What Gastroenterologists Need to Know

Corona virus disease-19 (COVID-19) is the latest global pandemic. COVID-19 is mainly transmitted through respiratory droplets and, apart from respiratory symptoms, patients often present with gastrointestinal symptoms and liver involvement. Given the high percentage of COVID-19 patients that present with gastrointestinal symptoms (GIS), in this review, we report a practical up-to-date reference for the physician in their clinical practice with patients affected by chronic gastrointestinal (GI) diseases (inflammatory bowel disease, coeliac disease, chronic liver disease) at the time of COVID-19. First, we summarised data on the origin and pathogenetic mechanism of SARS-CoV-2. Then, we performed a literature search up to December 2020 examining clinical manifestations of GI involvement. Next, we illustrated and summarised the most recent guidelines on how to adhere to GI procedures (endoscopy, liver biopsy, faecal transplantation), maintaining social distance and how to deal with immunosuppressive treatment. Finally, we focussed on some special conditions such as faecal-oral transmission and gut microbiota. The rapid accumulation of information relating to this condition makes it particularly essential to revise the literature to take account of the most recent publications for medical consultation and patient care.

Evolution of International Pediatric Endoscopic Practice Changes During the Coronavirus Disease 2019 Pandemic

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has drastically altered endoscopic practices. We initially reported the international impact of COVID-19 on pediatric endoscopic practice. This follow-up study aimed to assess changes 7 months following the initial survey to delineate practice change patterns as the pandemic evolved.

METHODS

Pediatric gastroenterologists who responded to the initial survey were re-surveyed seven months later using Research Electronic Data Capture (REDCap). The survey recorded information on changes in pediatric endoscopic practice patterns, including COVID-19 screening and testing processes and personal protective equipment (PPE) utilization. Additionally, endoscopists' risk tolerance of COVID-19 transmission was evaluated.

RESULTS

Seventy-five unique institutions from 21 countries completed surveys from the 145 initial responses (51.7% response rate). Procedural volumes increased at most institutions (70.7%) and most were performing previously postponed cases (90.7%). Ninety-seven percent of institutions were performing pre-endoscopy screening with 78.7% testing all patients. Many institutions (34.7%) have performed procedures on COVID-19 positive patients. There was significantly less PPE reuse (P  < 0.05) and fewer institutions recommending full PPE for all endoscopies (43.2% vs 59.2%, P = 0.013). Overall, pediatric endoscopists' risk tolerance of COVID-19 transmission is low.

CONCLUSIONS

This is the first survey to highlight the evolution of pediatric endoscopic practices related to the COVID-19 pandemic, underscoring the need for ongoing pandemic-related guidance for pediatric endoscopic practice.

Gastrointestinal, hepatic and pancreatic manifestations of COVID-19 in children

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a well-established respiratory tract pathogen. Recent studies in adults and children have shown an increasing number of patients reporting gastrointestinal manifestations of SARS-CoV-2 infection such as diarrhoea, nausea, vomiting and abdominal pain. SARS-CoV-2 RNA can be detected in faeces for an extended period, even after respiratory samples have tested negative and patients are asymptomatic. However, faecal-oral transmission has not yet been proven. In this article, the latest evidence on gastrointestinal, hepato-biliary, and pancreatic manifestations in children with coronavirus disease-19 and multisystem inflammatory syndrome will be analysed.

Epidemiology of Pediatric Foreign Body Ingestions Amidst the Coronavirus 2019 Pandemic at a Tertiary Care Children’s Hospital

Supplemental Digital Content is available in the text.

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COVID-19 and Pediatric Gastroenterology

Pediatric gastroenterologists took on a variety of challenges during the coronavirus disease 2019 pandemic, including learning about a new disease and how to recognize and manage it, prevent its spread among their patients and health professions colleagues, and make decisions about managing patients with chronic gastrointestinal and liver problems in light of the threat. They adapted their practice to accommodate drastically decreased numbers of in-person visits, adopting telehealth technologies, and instituting new protocols to perform endoscopies safely. The workforce pipeline was also affected by the impact of the pandemic on trainee education, clinical experience, research, and job searches.

Understanding and Responding to the Impact of COVID-19 on Paediatric Gastroenterology Training & Practice of Young ESPGHAN Members

OBJECTIVES

Limited data exist about the impact of the coronavirus disease 2019 (COVID-19) pandemic on the training and clinical practice of young doctors. The aim of this study was to evaluate the impact on paediatric gastroenterologists in training posts during the first wave of the European COVID pandemic.

METHODS

All Young members of European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) (YE) members received a multiple-choice questionnaire concerning the impact (if any) on their clinical practice, mental health, quality of care provided and fellowship/training experience. The survey was conducted between May 22, 2020 and June 10, 2020.

RESULTS

Of the 144 responders (40% of YE members), 85% (n = 123) reported an impact of COVID-19. Ninety-six percent reported an impact on their clinical practice, including more virtual patient consultation (n = 91), underutilization of ambulatory care (n = 113) and reduced or lack of planned admissions (n = 75). Endoscopy restrictions to semi-urgent or emergency cases were reported in 82 and lack of medical equipment/drugs (n = 47) were also reported.Reported adverse mental health issues included poor concentration, increased stress levels, an impact on family life in 62% and a reduced quality of care in 45%; this was more often reported in doctors from Southern Europe (54%) than in those from other geographical areas.Seventy-seven percent reported an impact on the content of their fellowship, including lack of participation in national/international meetings, withdrawn research time and limited mentoring.

CONCLUSIONS

The impact of the COVID-19 pandemic has been shown to affect the clinical practice, training and mental health of YE members. Adaptations of training programmes and targeted strategies to improve the clinical practice of young practitioners are needed and proposed in this manuscript.

Assessment of health equity consideration in masking/PPE policies to contain COVID-19 using PROGRESS-plus framework: a systematic review

INTRODUCTION

There is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. Policies and guidance for containing the infection and reducing the COVID-19 related deaths have proven to be effective, however the extent to which health inequity factors were considered in these policies is rather unknown. The aim of this study is to measure the extent to which COVID-19 related policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE).

METHODS

A systematic search for published documents on COVID-19 and masks/PPE was conducted across six databases: PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. Reviews, policy documents, briefs related to COVID-19 and masks/PPE were included in the review. To assess the extent of incorporation of equity in the policy documents, a guidance framework known as 'PROGRESS-Plus': Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, disability etc.) was utilized.

RESULTS

This review included 212 policy documents. Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component. Most of the policy documents (n = 163, 85.79%) focused on "occupation" component of the PROGRESS-plus followed by personal characteristics associated with discrimination (n = 4;2.11%), place of residence (n = 2;1.05%) and education (n = 1;0.53%). Subgroup analysis revealed that most of the policy documents (n = 176, 83.01%) were focused on "workers" such as healthcare workers, mortuary workers, school workers, transportation workers, essential workers etc. Of the remaining policy documents, most were targeted towards whole population (n = 30; 14.15%). Contrary to "worker focused" policy documents, most of the 'whole population focused' policy documents didn't have a PROGRESS-plus equity component rendering them equity limiting for the society.

CONCLUSION

Our review highlights even if policies considered health inequity during the design/implementation, this consideration was often one dimensional in nature. In addition, population wide policies should be carefully designed and implemented after identifying relevant equity related barriers in order to produce better outcomes for the whole society.

Surgical Perspectives for Pediatric Theater Teams during the SARS-CoV-2 Pandemic and Beyond: Narrative Review and Mandatory Tasks Guidelines

This is a narrative review during the ongoing coronavirus disease 2019 (COVID-19) pandemic to streamline workflow of pediatric surgical patients in operating theaters and for theater teams involved in their management. Pediatric patient anxiety in theaters, aspects of communication, and optimizing vision during surgery during the pandemic have also been addressed. The COVID-19 pandemic has led to the creation of pathways in the surgical management of patients. As the pandemic progressed, hospitals developed pathways to offer increased protection to staff during procedures. This narrative review provides a clear perspective in the management of pediatric patients in operating theaters. Guidelines received from National Health Authorities and Societies affiliated with surgery, endoscopic surgery, anesthesiology, and endoscopy were carefully reviewed regarding their recommendations and data emerging from reports on COVID-19 were selected to compile the pathways specific for pediatric patients and staff. The workflow pathways have been successfully implemented during the pandemic and include a section on patients for endoscopy as well as approach to endoscopic surgery and open procedures. Theater room ergonomics that were successful during the pandemic have been outlined along with identification of areas specific to the pediatric patient anxiety, interteam communication/identification, and visor-related vision. The guidelines used successfully during the pandemic for pediatric theater teams can be used or adapted for formulating local hospital guidelines in other centers that could be valuable in patient management beyond the pandemic.

"Endoshield": A Physical Protective Box for Pediatric Endoscopy during the COVID-19 Pandemic

Background/Aims

The coronavirus disease (COVID)-19 pandemic presents challenges for gastrointestinal endoscopy. Although the virus is transmitted through contact and droplets, aerosol-generating procedures produce aerosols that can spread through airborne routes. Several gastrointestinal societies have released statements to protect patients and health care providers (HCPs). This study describes a barrier box that may be used as an adjunctive device in addition to personal protective equipment during endoscopies.

Methods

A transparent acrylic box called "Endoshield" was created to place over patient's head and shoulders and was tested for its ease of use for the endoscopist and suitability for patient size and position.

Results

Twelve children (66.67%, male) with a median age of 9 years (range, 2-11 years) underwent emergency or urgent endoscopy between April and June 2020 during the COVID-19 outbreak. The most common presenting symptom was life-threatening gastrointestinal bleeding (8/12, 66.67%), while the rest had urgent symptoms (4/12, 33.33%). The "Endoshield" was suitable for all patient positions (left lateral position: 9/12, 75% and supine position: 3/12, 25%). The patients and HCPs were followed up for their symptoms on day 14, and none of them had any symptoms of concern.

Conclusions

The "Endoshield" is affordable, reusable, and suitable for both positions.

SARS-CoV-2 and the Gastrointestinal Tract in Children

Coronavirus disease 2019 (COVID-19), caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is predominantly a respiratory disease. However, its significant impact on the gastrointestinal (GI) system is now well-known. SARS-CoV-2 enters cells via the angiotensin-converting enzyme-2 (ACE-2) receptor, which is abundantly expressed on lung cells, but also on enterocytes. Several etiopathogenetic mechanisms have been postulated to explain the GI involvement in COVID-19, including loss in intestinal absorption, microscopic mucosal inflammation and impaired ACE-2 function, which plays a significant role in maintaining gut homeostasis. In children the GI manifestations include anorexia, nausea, vomiting, diarrhea and abdominal pain, which may represent the earliest presenting symptoms of the disease. However, although rare, a significant GI mucosal inflammation, such as terminal ileitis mimicking an atypical appendicitis, and other GI manifestations have been reported. COVID-19 pandemic has posed a significant challenge in healthcare provision in term of ability in providing safe diagnostic procedures, face-to-face consultations, and offering comprehensive care. For instance, changes in health services have raised the risk of empirical or sub-optimal management of chronic GI disorders such as inflammatory bowel disease (IBD) due to delayed endoscopic and clinical assessment. This review will discuss the acute GI involvement in COVID-19 in children and reflect on challenges and major changes observed in clinical practice during COVID-19 pandemic by sharing both the published literature and personal experience. We also suggest potential strategies for providing optimal gastroenterology care during this unprecedented era.

Pediatric Endoscopy During COVID-19 Times

The global COVID-19 pandemic has led to healthcare resources being diverted or stretched, especially during periods of lock-down in affected countries. Disruptions to normal services have resulted in reduced or delayed provision of endoscopy in many countries, with consequent impacts on diagnosis or management of digestive diseases and upon endoscopy training. This review article aims to highlight key aspects of the impact of the pandemic upon endoscopy services, with a focus upon endoscopy in children.

A Conceptual Framework for Rescheduling Elective Pediatric Gastroenterology Procedures Following COVID-19 Pandemic Lockdown

Elective surgical and endoscopic procedures were suspended nationwide during the March 2020 COVID-19 pandemic to minimize exposure and healthcare resource utilization. This resulted in an unprecedented backlog of procedures in most clinical practices including pediatrics. Our group developed an internal process toward the rational development of an algorithm prioritizing elective procedures. This was based on patient disease severity defined by the presence of alert symptoms, symptom severity for dysphagia and abdominal pain, and diagnostic investigation findings. The underlying rationale is to prioritize patients in whom suspected disease course would be greatest impacted by endoscopy. We developed a nurse phone call-based process utilizing REDCap®, identifying relevant symptoms categorized by severity, and a validated functional impairment questionnaire for abdominal pain. We abstracted key laboratory and radiological findings also categorized by severity. The order of priority of procedures was established on the basis of a 4-tiered system factoring both presence and severity of symptoms or prior diagnostic testing results. We present the framework that we have adopted toward prioritizing procedures with the assumption that it offers an objective methodology and that can be efficiently and more broadly applied to other similar practice scenarios. Our tool may have wide-ranging implications both in the current COVID-19 pandemic and in other scenarios of limited resource allocation and deserves further investigation.

COVID-19 pandemic and challenges in pediatric gastroenterology practice

The current coronavirus pandemic is imposing unpreceded challenges to the practice of pediatric gastroenterology. These are highlighted in their impact on performing aerosol-generating endoscopy procedures and the need to accommodate longer room turnaround time for disinfection, ensuring appropriate and consistent safety measures for patients, staff and providers, and emphasizing the importance for screening patients for active coronavirus disease (COVID) infection before endoscopy when possible. Pediatric patients are less likely to exhibit severe COVID-related symptoms so survey-based screening would not be a sensitive measure to identify patients with active infections. To address the restrictions of patients coming for face to face clinic encounters, there has been rapid expansion of telehealth services in a very short time period with several difficulties encountered. To survive these challenges, pediatric gastroenterology practices need to adapt and accept flexibility in clinical operations with ongoing commitment to safety for patients and healthcare workers.

The global impact of COVID-19 on gastrointestinal endoscopy units: An international survey of endoscopists

BACKGROUND & STUDY AIMS

Corona virus disease-19 (COVID-19) pandemic has markedly impacted routine medical services including gastrointestinal (GI) endoscopy. We aim to report the real-life performance in high volume GI endoscopy units during the pandemic.

PATIENTS AND METHODS

A web-based survey covering all aspects of daily performance in GI endoscopy units was sent to endoscopy units worldwide. Responses were collected and data were analyzed to reveal the effect of COVID-19 pandemic on endoscopy practice.

RESULTS

Participants from 48 countries (n = 163) responded to the survey with response rate of 67.35%. The majority (85%) decreased procedure volume by over 50%, and four endoscopy units (2.45%) completely stopped. The top three indications for procedures included upper GI bleeding (89.6%), lower GI bleeding (65.6%) and cholangitis (62.6%). The majority (93.9%) triaged patients for COVID-19 prior to procedure. N95 masks were used in (57.1%), isolation gowns in (74.2%) and head covers in (78.5%). Most centers (65%) did not extend use of N95 masks, however 50.9% of centers reused N95 masks. Almost all (91.4%) centers used standard endoscopic decontamination and most (69%) had no negative pressure rooms. Forty-two centers (25.8%) reported positive cases of SARS-CoV-2 infection among patients and 50 (30.7%) centers reported positive cases of SARS-CoV-2 infection among their healthcare workers.

CONCLUSIONS

Most GI endoscopy centers had a significant reduction in their volume and most procedures performed were urgent. Most centers used the recommended personal protective equipment (PPE) by GI societies however there is still a possibility of transmission of SARS-CoV-2 infection in GI endoscopy units.

Personal protective equipment for surgeons during COVID-19 pandemic: systematic review of availability, usage and rationing

BACKGROUND

Surgeons need guidance regarding appropriate personal protective equipment (PPE) during the COVID-19 pandemic based on scientific evidence rather than availability. The aim of this article is to inform surgeons of appropriate PPE requirements, and to discuss usage, availability, rationing and future solutions.

METHODS

A systematic review was undertaken in accordance with PRISMA guidelines using MEDLINE, Embase and WHO COVID-19 databases. Newspaper and internet article sources were identified using Nexis. The search was complemented by bibliographic secondary linkage. The findings were analysed alongside guidelines from the WHO, Public Health England, the Royal College of Surgeons and specialty associations.

RESULTS

Of a total 1329 articles identified, 95 studies met the inclusion criteria. Recommendations made by the WHO regarding the use of PPE in the COVID-19 pandemic have evolved alongside emerging evidence. Medical resources including PPE have been rapidly overwhelmed. There has been a global effort to overcome this by combining the most effective use of existing PPE with innovative strategies to produce more. Practical advice on all aspects of PPE is detailed in this systematic review.

CONCLUSION

Although there is a need to balance limited supplies with staff and patient safety, this should not leave surgeons treating patients with inadequate PPE.

Development of pediatric surgical decision-making guidelines for COVID-19 in a New York City children's hospital

OBJECTIVE

During the COVID-19 pandemic, experience-based guidelines are needed in the pediatric population in order to deliver high quality care in a new way that keeps patients and healthcare workers safe and maximizes hospital resource utilization.

BACKGROUND

The COVID-19 pandemic has created an unprecedented strain on national health care resources, particularly in New York City, the epicenter of the outbreak in the United States. Prudent allocation of surgical resources during the pandemic quickly became essential, and there is an unprecedented need to weigh the risks of operating versus delaying intervention in our pediatric patients.

METHODS

Here we describe our experience in surgical decision-making in the pediatric surgical population at Morgan Stanley Children's Hospital of New York-Presbyterian (MSCHONY), which has served as a major urban catchment area for COVID-19 positive pediatric patients. We describe how we have adjusted our current treatment of multiple facets of pediatric surgery including oncology, trauma, minimally invasive procedures, and extracorporeal membrane oxygenation (ECMO).

CONCLUSIONS

Our pediatric surgery department had to creatively and expeditiously adjust our protocols, guidelines, and workforce to not only serve our pediatric population but merge ourselves with our adult hospital system during the COVID pandemic.

TYPE OF STUDY

Clinical research paper LEVEL OF EVIDENCE: Level V.

Clinical Questions and Answers on Gastrointestinal Endoscopy during the Novel Coronavirus Disease 2019 pandemic

Some situations may require endoscopy during the COVID-19 (Coronavirus Disease 2019) pandemic. Here, we describe the necessary precautions in the form of clinical questions and answers (Q&A) regarding the safe deployment of gastrointestinal endoscopy in such situations while protecting endoscopy staff and patients from infection. Non-urgent endoscopy should be postponed. The risk of infection in patients should be evaluated in advance by questionnaire and body temperature. The health of staff must be checked every day. Decisions to employ endoscopy should be based on the institutional conditions and aims of endoscopy. All endoscopic staff need to wear appropriate personal protective equipment (PPE). The endoscope and other devices should be cleaned and disinfected after procedures in accordance with the relevant guidelines. Optimal management of the endoscopy unit is required. Endoscopy for infected patients or those with suspected infection demands exceptional caution. When a patient who undergoes endoscopy is later found to have COVID-19, the members of staff involved are considered exposed to the virus and must not work for at least 14 days if their PPE is considered insufficient. When PPE resources are limited, some equipment may be used continuously throughout a shift as long as it is not contaminated. Details of the aforementioned protective measures are described.

Development of pediatric surgical decision-making guidelines for COVID-19 in a New York City children's hospital

OBJECTIVE

During the COVID-19 pandemic, experience-based guidelines are needed in the pediatric population in order to deliver high quality care in a new way that keeps patients and healthcare workers safe and maximizes hospital resource utilization.

BACKGROUND

The COVID-19 pandemic has created an unprecedented strain on national health care resources, particularly in New York City, the epicenter of the outbreak in the United States. Prudent allocation of surgical resources during the pandemic quickly became essential, and there is an unprecedented need to weigh the risks of operating versus delaying intervention in our pediatric patients.

METHODS

Here we describe our experience in surgical decision-making in the pediatric surgical population at Morgan Stanley Children's Hospital of New York-Presbyterian (MSCHONY), which has served as a major urban catchment area for COVID-19 positive pediatric patients. We describe how we have adjusted our current treatment of multiple facets of pediatric surgery including oncology, trauma, minimally invasive procedures, and extracorporeal membrane oxygenation (ECMO).

CONCLUSIONS

Our pediatric surgery department had to creatively and expeditiously adjust our protocols, guidelines, and workforce to not only serve our pediatric population but merge ourselves with our adult hospital system during the COVID pandemic.

TYPE OF STUDY

Clinical research paper LEVEL OF EVIDENCE: Level V.

Coronavirus disease 2019 (COVID-19) and pediatric gastroenterology

The coronavirus disease 2019 (COVID-19) is responsible for the new pandemic, which remains an important health and economic challenge worldwide. The causative agent is a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is similar to SARS-CoV-1 and Middle East respiratory syndrome coronavirus (MERS-CoV). Adult infection with respiratory symptoms was considered in the beginning of the pandemic. Now, it has been reported that SARS-CoV-2 infects children and other organs such as the gastrointestinal tract. SARS-CoV-2 enters the host cells through angiotensin converting enzyme-2 (ACE2) receptors as the main receptor expressed in various organs such as the lungs and gastrointestinal tract. Studies on children and the clinical manifestations of COVID-19 do not completely explain the natural course of infection in children, and precisely how the GI tract is involved is not understood. The present article highlights the gastrointestinal manifestations and pathological findings in children with COVID-19. According to the evidence, SARS-CoV-2 infection is milder in children and may present different clinical symptoms from adults. Common clinical manifestations of pediatric COVID-19 include cough, fever, sore throat, malaise, fatigue, and GI symptoms such as diarrhea, abdominal pain, nausea, and vomiting. Furthermore, liver and pancreatic enzymes may be elevated during the pediatric COVID-19 course. Asymptomatic children carriers are potential sources of infection for adults, especially elderly ones. Diagnosis, treatment, and isolation of children are the most effective ways to control the expansion of the COVID-19 pandemic.