key: cord-1026943-w22ztq60
authors: Lohiya, Nirali; Lohiya, Nikhil; Karve, Smita; Agarkhedkar, Sharad
title: A Tale of COVID-19: Beyond Physical Ailment
date: 2020-12-26
journal: Indian Pediatr
DOI: 10.1007/s13312-021-2149-y
sha: bb9dd5f3a2d035584f66626ef0ff9054c32be2c8
doc_id: 1026943
cord_uid: w22ztq60

nan

We read with interest the recent article on ensuring exclusive human milk diet in COVID-19 times [1] , which covers practical aspects of newborn care and breastfeeding during the pandemic. However, it does not fully answer the pediatrician's query whether to practice rooming in, kangaroo mother care (KMC) and exclusive breastfeeding, when baby is positive/negative and when mother is positive and symptomatic/asymptomatic.

In general, COVID-19 pandemic has shown adverse effects on newborn nutrition and KMC. Many facilities consider separating neonates and mothers for unspecified periods, until the mother is non-contagious. It is known that temporary early separation and disruption of newborn physiology can affect immunity and increase the risk of infant hospitalization and double the burden on the health system [2] . Practicing KMC has been documented to improve breastfeeding rates compared to conventional neonatal care in COVID-19 [3] . The World Health Organization (WHO) recommends that infants and mothers with suspected/confirmed COVID-19 should be enabled to practice rooming-in and give skin-to-skin contact throughout day and night [4] .

In a study on 46 mother-infant dyads, three breastmilk samples tested positive for COVID-19 by RT-PCR and one out of three babies tested positive. This was not concluded as transfer through breastmilk, as there was also close contact with positive mother [4] . As there is no clear evidence of transfer of the virus through breastmilk, the general agreement is that stable neonates exposed to COVID-19 infection can be roomed-in with exclusive breastfeeding [5] . The mother-baby dyad must be isolated from other mothers. The neonate and the mother may be managed in separate isolation facility, if sick/ symptomatic [5] . The La Leche League International (LLI) stands firm in giving breastfeeding after observing good hygiene practices to reduce viral transfer. This will offer immunological protections to the breastfed baby, as mothers who become infected shortly before giving birth and those who become infected while breastfeeding, will produce specific secretory IgA antibodies and many other critical immune factors to protect their neonates. According to LLI, if someone who is breastfeeding becomes ill, it is important not to interrupt direct breastfeeding. The baby has already been exposed to the virus by the mother and/or the family and will benefit most from continued direct breastfeeding [6] . Therefore, rooming in, giving KMC and exclusive direct breastfeeding are recommended in newborns of COVID 19 suspected or confirmed mothers after taking adequate precautions like wearing mask and with strict hand hygiene practices and cough etiquette. Separation, KMC by another family member and giving expressed/donor milk may be practiced only if that is medically indicated, the mother or baby being critically ill.

A 9-year-4-month-old girl was referred to our child development clinic with complaints of on-and-off shortness of breath, crying episodes and excessive fear of the COVID-19 to herself and family members. These symptoms were present since a week. She was developmentally normal. She was reported as a bright and friendly child. No psychiatric illness was reported in any family members. The screen usage of family was increased significantly mainly related to news on the outbreak. Ten days back, her neighbours, including her close Since the initial days of the coronavirus disease 2019 (COVID-19) outbreak, there is increase in fear and anxiety in general population which is palpable worldwide [1] . Pandemics are known to cause short-and long-term mental health issues, particularly in children and adolescents [2] . VOLUME 58 __ FEBRUARY 15, 2021 CORRESPONDENCE friend, were moved to a hospital due to COVID-19. Parents reported that she had excessive fear thereafter of COVID-19. Her daily routine including appetite, sleep, play and class work was also affected. While conversing with the child she had moist eyes with mainly short answers to any questions asked. On probing further, she reported about the incident and her fear of separation from the parents if either of them got infected. She had nightmares of being infected with COVID-19. On asking her what she knows about COVID-19, she replied "it is a deadly virus which spreads from one person to another -once infected the person dies within a short time." Her vitals were stable and systemic examination revealed no significant findings. Looking at the clinical scenario, the child was diagnosed to have acute stress disorder with panic symptoms [3] .

Cognitive behavioural therapy (CBT) (3-4 sessions in a week) was initiated with a clinical psychologist, focused on restructuring her thoughts and cognition. Due to significant impairment of daily activities and sleep, clonazepam was started at the dosage of 0.5 mg/day in 2 divided doses. Relaxation techniques were advised at home. Parents were asked to decrease screen usage focussing on COVID-19 and to divert her in activities she relished.

Panic disorder, generalized anxiety disorder (GAD), specific phobia, and post-traumatic stress disorder were also considered in differential diagnosis. However, presence of triggering factor and duration of illness helped to rule out the differentials [3] . After one week, overall improvement was observed in the child, and parents reported her improved wellbeing. Medications were stopped and she was asked to follow up for CBT. The child is on follow-up and symptom free since 4 weeks.

Children are having an increased exposure to media and inadequate knowledge about pandemic. Some individuals can cope up with it. However, fear of the unknown raises anxiety levels in many children, especially the one with preexisting mental health conditions or neurodevelopmental disorders [2] . They may experience a broad range of concerns, including various internalizing and/or externalizing behavioral issues, increased substance abuse, social isolation, mental health disorders and lowered perceived good health [4] .

Proactive and empathetic approach not only to the exposed but also with the unexposed is required. Early pick up with comprehensive history and observation is crucial for diagnosis. Appropriate intervention and meticulous follow up can benefit such children to build resilience during these difficult times.

safety and efficacy in children. Recently a group of experts stated that the wait shall be prolonged for the pediatric age group due to the lack of clinical trials of COVID-19 vaccine in children and their vulnerable status [3] . However, explicit guidance from the Government of India on this aspect is not yet available. It is high time that the panel considers it as an urgent public health issue and advocates the right decision for children that is based upon robust scientific evidence and strong ethical aspects.

In a scientific view, the decision for vaccination should depend upon the overall disease prevalence and associated mortality and morbidity. For COVID-19, all these three aspects are relatively less severe in children, though due to the unknown status of the long-term implications, the situation remains grave. Another scientific aspect is the efficacy and safety of the vaccine in a given population. Unfortunately, similar to other therapeutic trials for COVID-19, the children are ostracized from vaccine trials too. Hence, this data is lacking at present and We welcome the recommendations of the Indian Academy of Pediatrics Advisory Committee on Vaccines and Immunization Practices (IAP-ACVIP) during the COVID-19 pandemic [1] . These recommendations are likely to assuage the doubts of pediatricians as well as parents. The Government of India is planning to layout the distribution of COVID-19 vaccine soon. In such times, the guidance from IAP-ACVIP regarding immunization of children with the COVID-19 vaccine is much desirable.

Recently a few vaccines have completed phase 3 trials and are likely to be available for the general population very shortly (Phase 4) [2] . Though the efficacy of these vaccines is impressive in trials among adults, there is apprehension for their

Ensuring Exclusive Human Milk Diet for All Babies in COVID-19 Times

Should infants be separated from mothers with COVID-19? First, do no harm

The effects of kangaroo mother care on the time to breastfeeding initiation among preterm and LBW infants: A meta-analysis of published studies

WHO, 2020. Accessed on

Perinatal-Neonatal Management of COVID-19 Infection -Guidelines of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP)

Continuing to nurse your baby through coronavirus

COVID-19) and other respiratory infections. La Leche League International

COVID-19: Psychological impact

The Psychology of pandemics: Preparing for the next global outbreak of infectious disease

Diagnostic and Statistical Manual of Mental Disorders

Public responses to the novel 2019 coronavirus (2019 nCoV) in Japan: Mental health consequences and target populations