In May 2020, multi-system inflammatory syndrome in children (MIS-C) started presenting in pediatric populations in Philadelphia. With vague symptoms and potentially severe manifestations, it was important to learn as much as possible—and quickly. Four nurses from the frontlines of Children’s Hospital of Philadelphia (CHOP), were among the first to better understand the diagnosis and management of MIS-C by conducting a literature review.
Children’s Hospital Today sat down with Kerry Shields, M.S.N., MBE, CRNP, CPNP-AC, pediatric critical care nurse practitioner, and Kristin Atlas, M.S.N., CRNP, CPNP-AC, ACCNS-P, a clinical nurse specialist, to discuss their publications and how they evaluated this emerging syndrome.
Since this is a relatively new syndrome, can you talk about how your research started? What were some of the challenges?
Shields: The editor of American Journal of Nursing approached Ruth Lebet, a nurse scientist at CHOP, to write a review article about MIS-C for nursing to better describe and understand this new entity. She needed a clinical perspective, so the three of us, including Jessica Farber, a pediatric critical care nurse practitioner, were able to help.
Atlas: This was all on a quick timeline and early in the discovery of MIS-C. We scoured databases to find anything that anyone was publishing, especially case reports; new data and new information would come out almost weekly, and it was constantly changing.
Shields: The initial publications were small case reports from single institutions, and there was no nomenclature established, so defining a consistent syndrome was difficult. It seemed like the scope of the research was changing every two days.
Atlas: After the initial review, we wanted to focus on critical care nursing and write an additional article highlighting how many elements of this evolving syndrome’s day-to-day management aligned with excellent nursing care.
What are some of the key similarities in sepsis and MIS-C that you’ve identified?
Atlas: The initial symptoms look very much like many common illnesses we see in pediatrics; GI symptoms, a fever, a rash and fatigue. That’s how many childhood illnesses present, so taking very common symptoms and then narrowing the options with more specific questions is important—especially regarding COVID-19 exposures and vaccination status.
Context matters. It’s important to sit with the family and understand their story—what’s the history of the child, family and community? Timing is also a major consideration; we generally see MIS-C present in two to six weeks after a potential or known COVID-19 exposure.
…and the differences?
Shields: The GI complaints were quite profound and that was different from what we were seeing in other inflammatory illnesses. In the workup of MIS-C, there can be significant cardiac dysfunction—myocarditis with left ventricular involvement. There were certainly other multisystem manifestations, but the care team really needs to have a high suspicion for cardiogenic shock and how quickly a seemingly well-appearing child can decompensate.
Specifically in MIS-C, children can seem well-appearing with these vague symptoms and then have a quick change in both their clinical appearance and the interventions that they're requiring.
Atlas: When comparing MIS-C to sepsis, one difference we talked about was the focus of the diagnostic work-up. With sepsis, we are looking for the infectious source. With MIS-C, we're trying to eliminate all other potential diagnoses and explain away all the other possibilities to definitively diagnosis this syndrome, per the CDC case definition.
How can children’s hospitals better equip themselves to care for kids with MIS-C both now and into the future?
Atlas: Identifying the resources and organizations that are publishing treatment guidelines is important. Information changes quickly as we learn more about COVID-19 and MIS-C on an almost daily basis, so it’s important to know where to find the answers, rather than relying on memorization of the most current recommendations.
Shields: It’s important to raise awareness. We want to keep everyone's diagnostic differential wide, yet inclusive. MIS-C should be added into an already wide differential, but it shouldn't take anything away, so finding that balance between something that is new and exciting while not becoming too focused on one diagnosis can be difficult. We should still concentrate on all the basic childhood illnesses, including sepsis, that still happen, even in the context of a pandemic.
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