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Arkalgud S. Applicability of virtual reality interventions for COVID-19 pediatric patients. HPHR. 2021;48.
DOI:10.54111/0001/VV5
The emergence of the Delta variant led to an increase in the number of children infected with SARS-CoV-2 [1, 2]. Research has shown that this age group is more susceptible to developing severe symptoms due to Delta variant infection, including hypoxia and severe shortness of breath. [1]. One study supported that two COVID-19 vaccine doses are approximately 88% effective at preventing symptomatic Delta variant disease [3]. However, research on the efficacy of COVID-19 vaccines in preventing this in young children is limited. Currently, children under 12 are not eligible to receive the COVID-19 vaccine [4].
From the start of the pandemic through September 2021, approximately 5.9 million children were diagnosed with COVID-19 in the U.S. Over the past two weeks, the number of pediatric cases has increased by 7% [5]. Thus far, only 0.1-1.9% of infected children and adolescents have required hospitalization; however, this group of patients, especially those who develop multisystem inflammatory syndrome (MIS-C), may require critical measures. These include non-invasive ventilation, invasive ventilation, and intravenous medications, namely, Remdesivir and inotropes [6-8]. The monoclonal antibody has been issued an Emergency Use Authorization (EUA) for high-risk adolescents over the age of 12 and is therefore not indicated for the treatment of younger children [9].
Though hospitalized pediatric patients are currently receiving life-saving treatments for COVID-19, they may be subject to stressful, uncomfortable, and potentially painful medical procedures [7,10]. The ensuing sensation of discomfort that children feel often leads to attempts to escape, which can cause poor procedure outcomes, extended procedure time, medical anxiety, and trauma due to a perceived lack of control [7,10]. Furthermore, these patients may develop feelings of stress and isolation during their hospital recovery, potentially impeding their social development [11]. Thus, an intervention that curbs these outcomes in ill pediatric patients may improve their hospital stay.
Studies have shown that virtual reality (VR) could abate children’s pain perception in emergency and intensive care settings, mitigate feelings of stress in intensive care and recovery units, and provide an engaging environment that promotes mobility during hospitalization [12]. This pharmacologic alternative involves immersing patients in simulated 3D spaces, engaging their visual and auditory pathways [13]. Although the exact mechanism of pain relief is unknown, VR sessions may decrease selective attention to painful stimuli and reduce activity in brain regions involved in pain perception networks, including the anterior cingulate gyrus and thalamus [14]. Some articles have reported the potential for dizziness, nausea, and eye strain in application users. More research is needed to quantify these risks [15].
Literature searches were conducted in PubMed and Centers for Disease Control from January 2016 to September 2021. Randomized control trials and case studies were used in this review article.
Virtual reality intervention studies were included if they met at least one of the following criteria:
Theoretically, selective attention involves focusing attention on a task and inhibiting the peripheral inputs or distractors [16]. Children less than nine years of age are more likely to be receptive to distractors, to an extent, compared to older children [16-18]. The proposed reason for this is their selective attention mechanisms are not fully developed, which, along with the time it takes to understand task instructions, contributes to the increased amount of time it takes for young children to perform tasks when given distractors [16-18]. Multiple brain areas may play a role in children’s ability to inhibit noxious stimuli processing, including the anterior cingulate cortex and dorsolateral prefrontal cortex [17]. A recent study indicated that GABAergic neurons in the central amygdala could also suppress pain perception [20]. Many of these brain regions continue to develop through adolescence, which is one reason why a solution that can moderate selective attention and pain sensitivity in children could be valuable [21].
Research on the use of VR for the treatment of COVID-19 pediatric patients in the emergency department is limited. However, virtual reality applications have demonstrated a decrease in fear, pain, and injection procedure time in school-aged children during intravenous access and medication administration in the emergency room [22]. Fear and pain were measured and compared using an age-appropriate, subjective scale. One of the possible explanations for the observed outcome is that VR interventions involve patient participation, which may be more effective than passive observation distractions in loud environments [23,24]. Thus, VR could be useful in physiologically stable COVID-19 isolation patients who are to receive IV fluids or medications in this setting.
After isolation and stabilization in the emergency department, severely ill pediatric COVID-19 patients may be admitted to intensive care units. Approximately 22% of children hospitalized for SARS-CoV-2 infection exhibit neurologic symptoms, varying from self-limiting manifestations to life-threatening disease [25]. [25]. These neurologic COVID-19 patients could undergo various tests to rule out complications such as severe encephalopathy and Guillain-Barre syndrome [26,27]. An example of this is lumbar puncture with cerebrospinal fluid analysis, which involves inserting a needle into the spinal column to withdraw sample fluid [28,29]. This procedure is performed for multiple, urgent conditions and is known to cause temporary low back pain and headaches in 11% and 27% of children respectively [25, 30, 31]. In one study involving adolescents diagnosed with cancer, the use of VR goggles was associated with decreased pain ratings during lumbar puncture [32]. Another study indicated that when used with anxiolytics, reduced the dose of pharmacologic medications needed to achieve analgesia and anxiolysis during the same procedure [33]. Therefore, this type of intervention may be beneficial in reducing lumbar puncture-related pain in adolescents diagnosed with COVID-19. There are no trials that outline the effect of VR on lumbar puncture pain in young children. Thus, further studies are needed to determine the outcome of this therapy in this patient group.
When children in critical condition recover in pediatric intensive care units (PICU), they may develop stress and neurocognitive sequelae [34]. One study of 3-17-year-old PICU patients supported that VR therapy was an immersive way for patients to relax [35]. Although this study did not establish a correlation between VR and anxiety, other studies have shown that VR may decrease anxiety symptoms in critically ill patients [36,37]. In one COVID- 19 rehabilitation unit in New York, a VR tool involving scenes of nature and stimulating games served as an interactive coping tool for adult patients suffering from the psychological impact of long-term hospitalization [12]. A similar method tailored to younger COVID-19 PICU patients could aid psychological well-being; however, more trials are needed to determine this effect.
Recovering patients may also develop motor weakness due to decreased mobility during their hospital stay. Studies on adult ICU patients have shown that VR exercise therapy can increase limb activity and assist rehabilitation when combined with physical therapy [38]. One outpatient trial showed that a 2-month-long tailored virtual reality exercise program improved adult COPD patients’ physical capacity and quality of life [39]. VR exercise programs may be applicable in pediatric patients recovering their respiratory function after COVID-19 hospitalization [1]. Although, this research has not been conducted on patients in acute respiratory distress.
Overall, research supports that virtual reality is a feasible tool for some pediatric patient groups to relieve fear, pain, stress, and motor weakness in medical settings. These therapies have shown efficacy in emergency departments, COVID-19 rehabilitation units, and ICUs. Therefore, VR may be an adequate adjunct to pharmacologic analgesia and physical therapy in hospitalized pediatric patients.
Future research on the usability of virtual reality interventions in critically ill patients with varying physical capabilities, respiratory support measures, and isolation precautions is needed. Studies comparing the efficacy of VR treatments with other digital distractors and the relationship between patient age and VR risks and benefits would be informative. More information is required to detail any risks associated with post-procedure and long-term VR therapy use in this maturing population.
Sahana Arkalgud is a physician assistant student who is passionate about supporting vulnerable patient populations.
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