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ACADEMIA Letters Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Ricardo Santos de Oliveira Matheus Fernando Manzolli Ballestero The world currently faces an outbreak of a respiratory disease named Coronavirus Disease 2019 (COVID-19), this acute respiratory syndrome is caused by the virus SARS-CoV-2 [1]. COVID-19 was recognized in December 2019 [2] and until April 2021, more than 12.8 million deaths were caused by the disease around the world [3]. The COVID-19 pandemic has infected over 131.435.555 million global-confirmed individuals worldwide with more than 2.854.923 million deaths as of April 5, 2021 [4]. While children infected with SARS-CoV-2 develop less severe forms of illness compared with adults, children are still at risk of complications and sequels from COVID-19. Although pediatric cases may be milder, children need greater hospital medical support and continuous assistance from their parents, generating a greater potential for transmissibility with nosocomial and community circulation of the virus. In addition, they can generate great social and financial burdens due to their parents’ absence from their own activities [5,6]. Since the first guideline to pediatric neurosurgery assistance during the pandemic was published in 2020 [7] few papers were published specifically about pediatric neurosurgical practice during the pandemic. The Brazilian Society of Pediatric Neurosurgery (SBNPed) was the first Pediatric Neurosurgical society to publish recommendations about surgery during the pandemic with the rationale: 1) to ensure an adequate treatment for patients, those with trauma, hemorrhage or severe infection, for example, who require immediate surgery; 2) to prepare and guide all the healthcare professionals on how to act, adequately protecting themselves with PPE; 3) to allow the minimum-required people in the surgical room, thus preventing the risk of contamination of other individuals [6]. Posteriorly SBNPed published a survey about the impact of the Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 1 COVID-19 pandemic on their clinical practice and a summary of recommendations regarding procedures and time for surgery [8]. As expected, neurosurgical practice was prejudiced. Meybodi et al. reported a reduction of 31% in pediatric neurosurgery at CMC, a tertiary referral center for pediatric neurosurgery in Iran, the decrease excluded brain and spinal tumors. These numbers can be explained by the referrals from other centers in the country. Authors also reported issues regarding education of residents and fellows attributing a significant deficiency in the pediatric neurosurgical residency education [9]. Many papers about COVID-19 and surgical practice come from Italy, where the pandemic struck Health System, early in 2020. Caraudo et al. reviewed pediatric neurosurgical activity at their institution (Neurosurgical Department of Giannina Gaslini Children’s Hospital in Genoa, Italy) from May 4 to July 15, 2020. Authors showed that Italian healthcare system is undertaking a process of reorganization of resources, in an attempt to restore all non-urgent activities while ensuring safety. After the emergency phase, they were learning to live together with COVID-19 and be prepared for the eventual second peak [10]. Wellons et al. highlighted the early lessons learned (April, 2020) in the management of COVID-19 for the pediatric neurosurgical community from the leadership of the American Society of Pediatric Neurosurgeons. They recommend restrictions to 1–2 entrances into the Children’s Hospitals, with a temperature screening and a series of symptom questions. Visitors for pediatric patients should be reduced to one adult for wards or clinics, with special permission required to rotate the visitor during the hospital stay. The initial dichotomy of elective versus emergency surgery was quickly found to be inadequate, as most subspecialties and cases began to be prioritized based on the level of harm over the anticipated delay in care [11]. Current protocols determine that surgeries have to be classified according to the level of emergency, simplifying this issue in a dangerous way. One must know that brain tumors will often become emergencies with the child having to be operated under worst clinical and neurological conditions. Carai et al. showed 4 cases of delayed referral of pediatric brain tumors related to the pandemic, indicating that children with brain tumors represent a fragile population exposed to the indirect effects of the COVID-19 pandemic. They argue that robust neurologic compensatory mechanisms in children, scarce familiarity with diagnostic clinical signs, and parental fear to expose children to the hospital environment contribute to explaining the poor clinical conditions recorded at the time of diagnosis [12]. Ahluwalia et al. in the beginning of the pandemic (May 2020) outlined the risks associated with delayed elective pediatric neurosurgery, concluding that evaluation of the timing Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 2 of a pediatric neurosurgery case must extend beyond the period of an imminent threat to the patient, they showed how adverse outcomes consistently arise when important optimum time windows of candidacy are missed. In addition, exposure risk and resource consumption in an era of scarcity have to be considered to attain the best overall decision regarding the timing of pediatric neurosurgical intervention [13,14]. Capozza et al. recommend that cancer treatments for pediatric patients should continue, without substantial interruptions or modifications. The multidisciplinary tumor boards have to continue to convene regularly and include call-conferences and telematics platforms in the routine. Authors argue that adequate knowledge and information are essential to avoid panic and excessive stress, thereby allowing early reporting of any suspected symptoms of cancer and, in turn, facilitating early diagnosis and prompt modulation of treatment [15]. Dysraphism surgeries as myelomeningocele and encephalocele are unavoidable and even craniosynostosis cannot be postponed for a long time. Narang et al. showed that even fetal surgery as myelomeningocele is under difficulties in the COVI-19, however , did not find statistical differences among the number of cases, indications, types of procedures, maternal age, gestational age, types of anesthesia, and duration of procedures compared to pre pandemic times [14]. Regarding the most frequent pediatric neurosurgery performed, shunt implant and revisions, Laxpati reported a reduction in shunt surgery in the beginning of the pandemic (MarchApril 2020), but no further information whether or not this trend continues or merely represents a delay in the presentation. [16]. So, the light at the end of the tunnel could be represented by a vaccine, but before COVID19 vaccines become available for younger teens and children, clinical trials need to be completed to ensure they are safe and effective for these age groups. Currently, (April, 2021) under way to test the Pfizer, Moderna, Oxford-AstraZeneca and Sinovac vaccines in children older than 3 years old [17]. Unfortunately, During the first 10 months of 2020, out of the 56 neurosurgeons who died, 36 were following COVID-19 infections [18]. In conclusion, neurosurgeons must be aware that the return to routine is far away. Until a massive vaccination, including children is available, institutional individualized protocols with presurgical SARS-CoV-2 testing, visitors entrance restrictions (with a temperature screening and a series of symptom questions), appropriate personal protective equipment and rational restriction of surgical procedures, having in mind the best time for surgery. Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 3 References 1- Qu YM, Kang EM, Cong HY. Positive result of Sars-Cov-2 in sputum from a cured patient with COVID-19. Travel medicine and infectious disease. 2020 Mar 1. 2- World Health Organization, World Health Organization (WHO). Pneumonia of unknown cause–China. Emergencies preparedness, response. Disease outbreak news, World Health Organization (WHO). 2020 Feb. 3- Dong E. Hongru Du, and Lauren Gardner. 2020.“. An Interactive Web-Based Dashboard to Track COVID-19 in Real Time.:30120-1. 4- Johns Hopkins University & Medicine Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) [Online]. 2021 [cited April 5, 2021] Available at: https://coronavirus.jhu.edu/map.html 5- Cui X, Zhao Z, Zhang T, Guo W, Guo W, Zheng J, Zhang J, Dong C, Na R, Zheng L, Li W. A systematic review and meta‐analysis of children with coronavirus disease 2019 (COVID‐19). Journal of medical virology. 2021 Feb;93(2):1057-69 6- Bi Q, Wu Y, Mei S, Ye C, Zou X, Zhang Z, Liu X, Wei L, Truelove SA, Zhang T, Gao W. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study. The Lancet Infectious Diseases. 2020 Aug 1;20(8):911-9. 7- de Oliveira RS, Ballestero MF. The COVID-19 outbreak and pediatric neurosurgery guidelines. Archives of Pediatric Neurosurgery. 2020 Apr 1;2(1 (January-April)):53-4. 8- Ballestero MF, Furlanetti L, de Oliveira RS. Pediatric neurosurgery during the COVID-19 pandemic: update and recommendations from the Brazilian Society of Pediatric Neurosurgery. Neurosurgical Focus. 2020 Dec 1;49(6):E2. 9- Meybodi KT, Habibi Z, Nejat F. The effects of COVID-19 pandemic on pediatric neurosurgery practice and training in a developing country. Child’s Nervous System. 2020 Nov 1:1-5. 10- Ceraudo M, Balestrino A, Cama A, Macrina G, Piatelli G, Consales A. Pediatric Neurosurgery After the COVID-19 Pandemic: Management Strategies from a Single Pediatric Hospital in Italy. World neurosurgery. 2021 Feb 1;146:e1079-82. 11- Wellons JC, Grant G, Krieger MD, Ragheb J, Robinson S, Weprin B, Ojemann J. EdAcademia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 4 itorial. Early lessons in the management of COVID-19 for the pediatric neurosurgical community from the leadership of the American Society of Pediatric Neurosurgeons. J Neurosurg Pediatr. 2020 Apr 10:1-2. 12- Carai A, Locatelli F, Mastronuzzi A. Delayed referral of pediatric brain tumors during COVID-19 pandemic. Neuro-oncology. 2020 Dec 18. 13- Ahluwalia R, Rocque BG, Shannon CN, Blount JP. The impact of imposed delay in elective pediatric neurosurgery: an informed hierarchy of need in the time of mass casualty crisis. Childs Nerv Syst. 2020 Jul;36(7):1347-1355. 14- Narang K, Elrefaei A, Wyatt MA, Warner LL, Trad AT, Segura LG, Bendel-Stenzel E, Ahn ES, Arendt KW, Qureshi MY, Ruano R. Fetal Surgery in the Era of SARS-CoV-2 Pandemic: A Single-Institution Review. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2020 Dec 1;4(6):717-24. 15- Capozza MA, Triarico S, Attinà G, Romano A, Mastrangelo S, Maurizi P, Frassanito P, Bianchi F, Verdolotti T, Gessi M, Balducci M, Massimi L, Tamburrini G, Ruggiero A; Gemelli Pediatric Neuro-Oncology Tumor Board. Managing children with brain tumors during the COVID-19 era: Don’t stop the care! Comput Struct Biotechnol J. 2021 Jan 12;19:705-709. 16- Laxpati N, Bray DP, Wheelus J, Hamilton K, Boydston W, Reisner A, Sawvel M, Chern JJ. Unexpected Decrease in Shunt Surgeries Performed during the Shelter-in-Place Period of the COVID-19 Pandemic. Oper Neurosurg (Hagerstown). 2021 Jan 11:opaa461. doi: 10.1093/ons/opaa461. Epub ahead of print. 17- Mahase E. Covid vaccine could be rolled out to children by autumn BMJ 2021; 372:n723 18- Akhaddar A. Letter to the Editor: Neurosurgeon Deaths from COVID-19 During the Past 10 Months (January to October 2020): We Do Not Forget Them. World Neurosurg. 2021 Feb;146:386-388 Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 5
ACADEMIA Letters Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Ricardo Santos de Oliveira Matheus Fernando Manzolli Ballestero The world currently faces an outbreak of a respiratory disease named Coronavirus Disease 2019 (COVID-19), this acute respiratory syndrome is caused by the virus SARS-CoV-2 [1]. COVID-19 was recognized in December 2019 [2] and until April 2021, more than 12.8 million deaths were caused by the disease around the world [3]. The COVID-19 pandemic has infected over 131.435.555 million global-confirmed individuals worldwide with more than 2.854.923 million deaths as of April 5, 2021 [4]. While children infected with SARS-CoV-2 develop less severe forms of illness compared with adults, children are still at risk of complications and sequels from COVID-19. Although pediatric cases may be milder, children need greater hospital medical support and continuous assistance from their parents, generating a greater potential for transmissibility with nosocomial and community circulation of the virus. In addition, they can generate great social and financial burdens due to their parents’ absence from their own activities [5,6]. Since the first guideline to pediatric neurosurgery assistance during the pandemic was published in 2020 [7] few papers were published specifically about pediatric neurosurgical practice during the pandemic. The Brazilian Society of Pediatric Neurosurgery (SBNPed) was the first Pediatric Neurosurgical society to publish recommendations about surgery during the pandemic with the rationale: 1) to ensure an adequate treatment for patients, those with trauma, hemorrhage or severe infection, for example, who require immediate surgery; 2) to prepare and guide all the healthcare professionals on how to act, adequately protecting themselves with PPE; 3) to allow the minimum-required people in the surgical room, thus preventing the risk of contamination of other individuals [6]. Posteriorly SBNPed published a survey about the impact of the Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 1 COVID-19 pandemic on their clinical practice and a summary of recommendations regarding procedures and time for surgery [8]. As expected, neurosurgical practice was prejudiced. Meybodi et al. reported a reduction of 31% in pediatric neurosurgery at CMC, a tertiary referral center for pediatric neurosurgery in Iran, the decrease excluded brain and spinal tumors. These numbers can be explained by the referrals from other centers in the country. Authors also reported issues regarding education of residents and fellows attributing a significant deficiency in the pediatric neurosurgical residency education [9]. Many papers about COVID-19 and surgical practice come from Italy, where the pandemic struck Health System, early in 2020. Caraudo et al. reviewed pediatric neurosurgical activity at their institution (Neurosurgical Department of Giannina Gaslini Children’s Hospital in Genoa, Italy) from May 4 to July 15, 2020. Authors showed that Italian healthcare system is undertaking a process of reorganization of resources, in an attempt to restore all non-urgent activities while ensuring safety. After the emergency phase, they were learning to live together with COVID-19 and be prepared for the eventual second peak [10]. Wellons et al. highlighted the early lessons learned (April, 2020) in the management of COVID-19 for the pediatric neurosurgical community from the leadership of the American Society of Pediatric Neurosurgeons. They recommend restrictions to 1–2 entrances into the Children’s Hospitals, with a temperature screening and a series of symptom questions. Visitors for pediatric patients should be reduced to one adult for wards or clinics, with special permission required to rotate the visitor during the hospital stay. The initial dichotomy of elective versus emergency surgery was quickly found to be inadequate, as most subspecialties and cases began to be prioritized based on the level of harm over the anticipated delay in care [11]. Current protocols determine that surgeries have to be classified according to the level of emergency, simplifying this issue in a dangerous way. One must know that brain tumors will often become emergencies with the child having to be operated under worst clinical and neurological conditions. Carai et al. showed 4 cases of delayed referral of pediatric brain tumors related to the pandemic, indicating that children with brain tumors represent a fragile population exposed to the indirect effects of the COVID-19 pandemic. They argue that robust neurologic compensatory mechanisms in children, scarce familiarity with diagnostic clinical signs, and parental fear to expose children to the hospital environment contribute to explaining the poor clinical conditions recorded at the time of diagnosis [12]. Ahluwalia et al. in the beginning of the pandemic (May 2020) outlined the risks associated with delayed elective pediatric neurosurgery, concluding that evaluation of the timing Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 2 of a pediatric neurosurgery case must extend beyond the period of an imminent threat to the patient, they showed how adverse outcomes consistently arise when important optimum time windows of candidacy are missed. In addition, exposure risk and resource consumption in an era of scarcity have to be considered to attain the best overall decision regarding the timing of pediatric neurosurgical intervention [13,14]. Capozza et al. recommend that cancer treatments for pediatric patients should continue, without substantial interruptions or modifications. The multidisciplinary tumor boards have to continue to convene regularly and include call-conferences and telematics platforms in the routine. Authors argue that adequate knowledge and information are essential to avoid panic and excessive stress, thereby allowing early reporting of any suspected symptoms of cancer and, in turn, facilitating early diagnosis and prompt modulation of treatment [15]. Dysraphism surgeries as myelomeningocele and encephalocele are unavoidable and even craniosynostosis cannot be postponed for a long time. Narang et al. showed that even fetal surgery as myelomeningocele is under difficulties in the COVI-19, however , did not find statistical differences among the number of cases, indications, types of procedures, maternal age, gestational age, types of anesthesia, and duration of procedures compared to pre pandemic times [14]. Regarding the most frequent pediatric neurosurgery performed, shunt implant and revisions, Laxpati reported a reduction in shunt surgery in the beginning of the pandemic (MarchApril 2020), but no further information whether or not this trend continues or merely represents a delay in the presentation. [16]. So, the light at the end of the tunnel could be represented by a vaccine, but before COVID19 vaccines become available for younger teens and children, clinical trials need to be completed to ensure they are safe and effective for these age groups. Currently, (April, 2021) under way to test the Pfizer, Moderna, Oxford-AstraZeneca and Sinovac vaccines in children older than 3 years old [17]. Unfortunately, During the first 10 months of 2020, out of the 56 neurosurgeons who died, 36 were following COVID-19 infections [18]. In conclusion, neurosurgeons must be aware that the return to routine is far away. Until a massive vaccination, including children is available, institutional individualized protocols with presurgical SARS-CoV-2 testing, visitors entrance restrictions (with a temperature screening and a series of symptom questions), appropriate personal protective equipment and rational restriction of surgical procedures, having in mind the best time for surgery. Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 3 References 1- Qu YM, Kang EM, Cong HY. Positive result of Sars-Cov-2 in sputum from a cured patient with COVID-19. Travel medicine and infectious disease. 2020 Mar 1. 2- World Health Organization, World Health Organization (WHO). Pneumonia of unknown cause–China. Emergencies preparedness, response. Disease outbreak news, World Health Organization (WHO). 2020 Feb. 3- Dong E. Hongru Du, and Lauren Gardner. 2020.“. An Interactive Web-Based Dashboard to Track COVID-19 in Real Time.:30120-1. 4- Johns Hopkins University & Medicine Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) [Online]. 2021 [cited April 5, 2021] Available at: https://coronavirus.jhu.edu/map.html 5- Cui X, Zhao Z, Zhang T, Guo W, Guo W, Zheng J, Zhang J, Dong C, Na R, Zheng L, Li W. A systematic review and meta‐analysis of children with coronavirus disease 2019 (COVID‐19). Journal of medical virology. 2021 Feb;93(2):1057-69 6- Bi Q, Wu Y, Mei S, Ye C, Zou X, Zhang Z, Liu X, Wei L, Truelove SA, Zhang T, Gao W. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study. The Lancet Infectious Diseases. 2020 Aug 1;20(8):911-9. 7- de Oliveira RS, Ballestero MF. The COVID-19 outbreak and pediatric neurosurgery guidelines. Archives of Pediatric Neurosurgery. 2020 Apr 1;2(1 (January-April)):53-4. 8- Ballestero MF, Furlanetti L, de Oliveira RS. Pediatric neurosurgery during the COVID-19 pandemic: update and recommendations from the Brazilian Society of Pediatric Neurosurgery. Neurosurgical Focus. 2020 Dec 1;49(6):E2. 9- Meybodi KT, Habibi Z, Nejat F. The effects of COVID-19 pandemic on pediatric neurosurgery practice and training in a developing country. Child’s Nervous System. 2020 Nov 1:1-5. 10- Ceraudo M, Balestrino A, Cama A, Macrina G, Piatelli G, Consales A. Pediatric Neurosurgery After the COVID-19 Pandemic: Management Strategies from a Single Pediatric Hospital in Italy. World neurosurgery. 2021 Feb 1;146:e1079-82. 11- Wellons JC, Grant G, Krieger MD, Ragheb J, Robinson S, Weprin B, Ojemann J. EdAcademia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 4 itorial. Early lessons in the management of COVID-19 for the pediatric neurosurgical community from the leadership of the American Society of Pediatric Neurosurgeons. J Neurosurg Pediatr. 2020 Apr 10:1-2. 12- Carai A, Locatelli F, Mastronuzzi A. Delayed referral of pediatric brain tumors during COVID-19 pandemic. Neuro-oncology. 2020 Dec 18. 13- Ahluwalia R, Rocque BG, Shannon CN, Blount JP. The impact of imposed delay in elective pediatric neurosurgery: an informed hierarchy of need in the time of mass casualty crisis. Childs Nerv Syst. 2020 Jul;36(7):1347-1355. 14- Narang K, Elrefaei A, Wyatt MA, Warner LL, Trad AT, Segura LG, Bendel-Stenzel E, Ahn ES, Arendt KW, Qureshi MY, Ruano R. Fetal Surgery in the Era of SARS-CoV-2 Pandemic: A Single-Institution Review. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2020 Dec 1;4(6):717-24. 15- Capozza MA, Triarico S, Attinà G, Romano A, Mastrangelo S, Maurizi P, Frassanito P, Bianchi F, Verdolotti T, Gessi M, Balducci M, Massimi L, Tamburrini G, Ruggiero A; Gemelli Pediatric Neuro-Oncology Tumor Board. Managing children with brain tumors during the COVID-19 era: Don’t stop the care! Comput Struct Biotechnol J. 2021 Jan 12;19:705-709. 16- Laxpati N, Bray DP, Wheelus J, Hamilton K, Boydston W, Reisner A, Sawvel M, Chern JJ. Unexpected Decrease in Shunt Surgeries Performed during the Shelter-in-Place Period of the COVID-19 Pandemic. Oper Neurosurg (Hagerstown). 2021 Jan 11:opaa461. doi: 10.1093/ons/opaa461. Epub ahead of print. 17- Mahase E. Covid vaccine could be rolled out to children by autumn BMJ 2021; 372:n723 18- Akhaddar A. Letter to the Editor: Neurosurgeon Deaths from COVID-19 During the Past 10 Months (January to October 2020): We Do Not Forget Them. World Neurosurg. 2021 Feb;146:386-388 Academia Letters, July 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: Ricardo Santos de Oliveira, rsoliveira30@gmail.com Citation: Santos de Oliveira, R., Manzolli Ballestero, M.F. (2021). Pediatric Neurosurgery during COVID-19 pandemic: where we are now and future perspectives. Academia Letters, Article 1561. https://doi.org/10.20935/AL1561. 5