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Review of MIS-C Clinical Protocols and Diagnostic Pathways: Towards a Consensus Algorithm
Ashley Tritt1,2, Ikram-Nour Abda3, Nagib Dahdah4
1Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada.
Insights
Pediatric centers rapidly developed clinical pathways for multisystem inflammatory syndrome in children (MIS-C) during the COVID-19 pandemic. While initial investigations showed agreement, further assessment of these evolving MIS-C protocols is needed.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Pathway Development
- Pandemic Response
Background:
- The COVID-19 pandemic spurred the creation of institutional clinical pathways for multisystem inflammatory syndrome in children (MIS-C).
- These pathways were largely based on expert opinion due to the novel nature of MIS-C.
- North American pediatric centers adapted their approaches to diagnosing and managing MIS-C.
Purpose of the Study:
- To assess how North American pediatric centers adapted to MIS-C during the pandemic.
- To analyze the agreement among institutional algorithms for tiered clinical investigations in MIS-C patients.
- To propose a composite algorithm based on common practices.
Main Methods:
- Evaluation of MIS-C diagnostic algorithms from 50 tertiary centers in the US and Canada (May 2020-December 2021).
- Data obtained through online searches and professional networks.
- Descriptive statistics were employed to analyze the collected algorithms.
Main Results:
- All pathways utilized a tiered investigation approach, with most mandating COVID-19 PCR testing.
- Basic biochemical workups were universal, while specialized tests like cardiac biomarkers were secondary.
- Significant variation existed in the tier distribution for urine studies, blood cultures, chest radiography, and COVID-19 serology.
Conclusions:
- Pediatric institutions demonstrated rapid adaptation and standardization of MIS-C evaluation amidst evolving knowledge.
- Most pathways converged on initial basic screening and secondary cardiac investigations.
- Comparative assessment of the efficacy and superiority of these hastily developed MIS-C protocols is warranted.
Background:
The emergence of multisystem inflammatory syndrome in children (MIS-C) during the severe acute respiratory syndrome coronavirus 2 pandemic led to the development of institutional clinical pathways based on expert opinion. We assessed North American paediatric centres' adaptation to MIS-C and analysed the degree of agreement between algorithms on tiered clinical investigations.
Methods:
This study evaluated MIS-C diagnostic algorithms from 50 tertiary centres developed between May 2020 and December 2021 in the United States and Canada obtained online and through colleagues in various institutions. Descriptive statistics were used to analyse results.
Results:
All clinical pathways used a tiered approach, and most required coronavirus disease 2019 polymerase chain reaction testing on presentation. Over one-quarter used a 24-hour fever to initiate investigations, and another quarter used 3 days. Basic biochemical workup was performed in all centres on presentation (complete blood count, inflammatory markers, hepatic, and renal functions). Specialized investigation was generally reserved for secondary testing (cardiac biomarkers, electrocardiogram and echo, and coagulation panel). Institutions were divided on several investigations for tier distribution, including urine studies, blood cultures, chest radiograph, and severe acute respiratory syndrome coronavirus 2 serology. Subspecialty consultations were reserved for second-line testing, including cardiology, infectious disease, and rheumatology. Finally, we propose a composite algorithm representative of the consulted pathways.
Conclusions:
Faced with an unprecedented clinical challenge, paediatric institutions responded swiftly with evaluation standardization, adapting to evolving knowledge. Most pathways agreed on initial basic screening tests followed by secondary workup including cardiac investigations. These protocols, developed during a high level of uncertainty, require comparative assessment on efficacy and superiority.
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