Emerging Reports Point To Dramatic Increase Of COVID-19 Cases In Children

With the school year beginning throughout the United States, multiple studies and reports suggest a rising incidence of the COVID-19 virus in children and note emerging findings about potential transmission of the virus from children. 

As of August 6, there was a 90 percent increase in new cases of COVID-19 over a four-week period among American children as reported by the American Academy of Pediatrics.¹ In the state of Florida alone, between July and August, pediatric cases rose by 137 percent, according to the Florida Department of Health.² 

Additionally, recently published research out of South Korea notes that children between the ages of 10 and 19 can transmit the virus at rates similar to adults.³ Another new study in JAMA Pediatrics adds that younger children with COVID-19 may carry higher viral loads in their noses as well.⁴ These statistics and findings are in conflict with previous perceptions that children were not major contributors to SARS-CoV-2 spread. 

Nicholas Pagano, DPM, FACFAS shares that his practice screens children just like adult patients with respect to COVID-19, including a pre-appointment questionnaire, temperature assessment and use of hand sanitizer. His practice requires that one parent accompany the child in the office and that all patients and staff wear masks for protection. 

“There are certain situations, whether it is a child’s anxiety or special needs, that require two parents to be present and we allow this,” says Dr. Pagano, the Vice President of the American College of Foot and Ankle Pediatrics. “Also, kids tend to move around a lot so in between our pediatric patients, we take extra time to sanitize the room, including surface areas not normally contacted by our adult patients.” 

Dr. Pagano points out that the parent plays a critical role in protecting young patients during office visits. He or she can assist with mask management and hand sanitizing to help the appointment run more smoothly. 

Joanne Balkaran, DPM, CWS, FACFAS currently utilizes similar protocols in her practice. She adds that she does not require patients under two years of age to wear masks. 

Although Dr. Pagano relates that schools in his area have opted to begin the academic year completely virtually, he cautions providers not to allow this decrease in exposure to influence in-office protection protocols. 

Dr. Balkaran agrees, stating that school scenarios will not change her office policies. 

“Children make up just over nine percent of total cases in states that report cases by age. Those who are 10 to 19 years of age appear to transmit COVID-19 at higher rates than younger children,” notes Dr. Balkaran, who is in private practice in Mount Dora, Fla. 

She says at-home learning “may be the safest avenue to prevent infection.” 

Pointing out that it may take more time to definitively clarify the trends suggested by the aforementioned studies, Dr. Pagano feels the most important part of this emerging information is the need for hand and face hygiene. He stresses that regardless of limitations in current study data, it is crucial to take proactive steps for all patients, including children. 

Does BMI Have An Impact In Outcomes For Arthroscopic Ankle Stabilization? 

By Jennifer Spector, DPM, FACFAS, Associate Editor

Patients with a higher body mass index (BMI) may experience similar results to their peers at a lower weight when undergoing the all inside arthroscopic Broström procedure for chronic lateral ankle instability. 

In a recently published study in the Journal of Foot and Ankle Surgery involving 113 patients, researchers reviewed visual analog pain scales, American Orthopedic Foot and Ankle Society (AOFAS) scales and the Foot Function Index. They found no significant difference in these outcomes between patients with BMIs over and under 30 kg/m². 

James Cottom, DPM, FACFAS, the lead author of the study, shares that the all inside arthroscopic Broström procedure has eliminated the need to use traditional open incisions in his practice due to “reproducible, reliable and excellent results” across his patient population. 

“This procedure augmented with a proximal anchor in the fibula is a valid option for treating chronic lateral ankle instability,” maintains Dr. Cottom, the Fellowship Director for the Florida Orthopedic Foot and Ankle Center in Sarasota, Fla. 

Pointing out that previous studies state that obese patients over 250 pounds or those with a higher BMI are not good candidates for a modified Broström procedure, Dr. Cottom feels this study shows this may not be the case. 

“We show that patients with a BMI over 30 do very well with this procedure,” notes Dr. Cottom. He adds that another study, recently submitted for publication, examines five-year outcomes with this procedure and shows “excellent results.” 

Dr. Cottom says his practice uses the same workup on all patients with chronic lateral ankle instability, regardless of BMI, including appropriate pre-operative treatment and functional rehabilitation. 

If non-surgical treatment fails and the patient elects surgery, Dr. Cottom says he follows the same post-op course for all patients no matter their BMIs. He allows immediate weightbearing in a tall CAM boot, which stays on for four weeks and formal physical therapy begins at three weeks postoperatively. At the four week postoperative appointment, he transitions patients into a functional ankle brace. Dr. Cottom advises patients to wear the ankle brace for daily activities for three months and then for vigorous physical activity only for another three months. 

Can Unilateral Charcot Arthropathy Be A Predictor Of Contralateral Pathology? 

By Jennifer Spector, DPM, FACFAS, Associate Editor 

What midterm outcomes might providers expect for patients with Charcot arthropathy, especially with respect to the contralateral foot? Examining rates of contralateral Charcot, ulceration and amputation in 130 patients with an average of 6.2 years of follow up, the authors of a recently published study in Foot and Ankle International note sobering statistics. 

Contralateral ulceration occurred in 46.2 percent of those studied while nearly 20 percent of patients developed contralateral Charcot arthropathy. Of those that did experience the additional onset of Charcot, 60 percent developed an ulcer, according to the study. The study authors note that every sixth patient studied required at least one amputation. 

Laura Shin, DPM, PhD, a co-author of the study, states she sees a similar percentage of contralateral Charcot neuroarthopathy in her practice but fewer amputations than she saw with this study. She attributes this to a team-based approach at the Keck Medicine of the University of Southern California that includes vascular, plastics and podiatry. 

Nicholas Bevilacqua, DPM, FACFAS also sees similar rates of contralateral Charcot in his practice. He also notes a seemingly higher incidence in younger patients and kidney or kidney-pancreas transplant patients. 

Noman Siddiqui, DPM, MHA, the Director of Podiatric Surgery at the International Center for Limb Lengthening in Baltimore, feels that surgeons well-versed in Charcot reconstruction also see the increased risks of contralateral pathology and morbidity. However, he says the study provides important data on how often these complications occur. 

“This study highlights the importance of closely monitoring and appropriately treating the unaffected foot throughout the course of treatment in patients with Charcot neuroarthropathy,” says Dr. Bevilacqua, who is in private practice in Teaneck, N.J. 

While he notes that offloading is crucial for successful outcomes in these cases, Dr. Bevilacqua cautions that certain offloading modalities can actually place the contralateral limb at risk by increasing plantar pressure to the unaffected side. 

Dr. Shin agrees that vigilance is key in this patient population. 

“One should take contralateral X-rays at the initial evaluation and examination,” notes Dr. Shin, an Assistant Professor of Clinical Surgery at the Keck School of Medicine at the University of Southern California. “Continue to monitor temperature in both extremities and prescribe diabetic shoes and boots for the contralateral limb while treating the side with Charcot changes. 

“We truly treat Charcot like cancer. Look for signs of recurrence and spread to other areas during the remission period. The complications can be extremely severe for these patients.” 

1. American Academy of Pediatrics. Children and COVID-19: state-level data report. Available at: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid- 19-state-level-data-report/ . Published August 6, 2020. Accessed August 14, 2020. 

2. Flores R, Weisfeldt S. Florida’s COVID-19 cases in children have increased 137 percent in past month. CNN Health. Available at: https://www. cnn.com/2020/08/11/health/florida-coronavirus-children/index.html . Published August 11, 2020. Accessed August 14, 2020. 

3. Park YJ, Choe YJ, Park O, et al. Contact tracing during coronavirus disease outbreak, South Korea, 2020. CDC Emerging Infectious Diseases. Online ahead of print. Available at: https://wwwnc.cdc.gov/eid/ article/26/10/20-1315_article . Accessed August 14, 2020. 

4. Heald-Sargent T, Muller WJ, Zheng X, et al. Age-related differences in nasopharyngeal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) levels in patients with mild to moderate coronavirus disease 2019. JAMA Pediatrics. Online ahead of print. Available at: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2768952 . Published July 30, 2020. Accessed August 14, 2020.