Pediatric Management

Last updated: 10-04-2020

General Information

 

Epidemiology

  • There is limited data on the epidemiology of COVID-19 infections in children.

  • A recent review of 72,314 cases by the Chinese Center for Disease Control and Prevention showed that less than 1% of the cases were in children younger than 10 years of age, and 1% of cases were in children between age 10 to 19 years of age [4]

  • In another study of 2143 pediatric patients in China, one child of 14 years of age died, while most cases were mild, with much fewer severe and critical cases (5.9%) than adult patients (18.5%) [5]

  • Korean literature suggests 4.8% of cases were in the 0 to 19 year old population [3]

  • Based on US numbers for persons aged ≤19 years [6]:

    • 5% of cases had COVID infection

    • No fatalities

    • 1.6-2.5% hospitalization rate

    • No ICU admissions 

 

Signs and Symptoms: [7, 8]

  • Cough (48.5%)

  • Pharyngeal erythema (46.2%)

  • Fever of at least 37.5 degrees C (41.5%)

  • Tachycardia (42.1%)

  • Tachypnea (28.7%)

  • Diarrhoea (8.8%)

  • Fatigue (7.6%)

  • Rhinorrhea (7.6%)

  • Vomiting (6.4%)

  • O2 saturation less than 92% (2.3%)

  • Accompanied by:

    • myalgia

    • nasal congestion

    • sneezing

    • sore throat

    • headache

    • dizziness

    • vomiting

    • abdominal pain

  • A few children do not exhibit fever, but only manifest cough or diarrhea, and even fewer can be asymptomatic carriers

  • Atypical symptoms:

    • vomiting, diarrhea, and other gastrointestinal symptoms, or only symptoms of shortness of breath

 

**Symptoms may be indifferentiable from infections like RSV, influenza A/B, or other viral infections, therefore nasopharyngeal swabs may be used for testing for multiple potential viruses.

Lab/Imaging Findings [7]

  • Lab:

    • Neutrophilia (4.6%)

    • Neutropenia (6.0%)

    • Lymphocytopenia (3.0%)

    • C-reactive protein elevated (13.6%)

    • Procalcitonin elevated (10.6%)

  • Imaging:

    • Ground glass opacity (33.3 %)

    • Local patchy shadowing (18.7%)

    • Bilateral patchy shadowing (12.3%)

    • No symptoms of infections or radiological features of pneumonia (15.8%)

Management

  • Generally, children with COVID-19 infection require only supportive care, unless they may have exacerbated symptoms due to underlying medical conditions.

  • Supportive therapy can include:

    • low flow oxygen

    • antipyretic and analgesics. There is currently no evidence that NSAID use should be avoided in patients with suspected or confirmed Covid-19 infection over 6 months of age.

    • maintenance of hydration status and electrolyte balance

    • optimizing nutrition especially with prolonged hospitalizations

    • escalation of care on an as-needed basis for high flow oxygen, BIPAP/CPAP with appropriate protective measures against aerosol generating procedures.

  • Ensure patients with comorbid conditions such as asthma are adequately treated as per their asthma action plan. The Canadian Thoracic Society has recommendations that can help guide alternate therapies for patients facing MDI medication shortages.[9]

  • Newborns with COVID suspected or confirmed positive mothers, may be choose to breastfeed and practice skin-to-skin care with precautions including washing hands with soap and water and donning a surgical/procedure mask to reduce the risk of droplet transmission during breastfeeding. They may also choose to use a pump, taking care to clean equipment between uses.

  • Infants who present with respiratory distress symptoms at or within minutes of birth are most likely to have a non-Covid illness with the usual differential diagnoses and management.

  • There is little evidence to vertical transmission, and few cases of horizontal transmission in the neonatal population.

  • No antivirals specific to Covid-19 infection are available. According to the CDC, Lopinavir/ritonavir and interferon-alpha have been used for treatment in children with COVID-19, however safety and efficacy of these drugs are unknown [2]

 

 

Additional Resources from the Canadian Pediatric Society are available at the link below. These include statements regarding best practices for pediatric office spaces, resources for anxiety and mental health for children and adolescents, parents of children with ADHD, as well as statements addressing needs of children with immune suppression, asthma, type 1 diabetes and other chronic medical conditions.

https://www.cps.ca/en/tools-outils/covid-19-information-and-resources-for-paediatricians

 

References

  1. Coronavirus Disease-2019 (COVID-19) and Children [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Mar19]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prepare/children-faq.html

  2. Information for Pediatric Healthcare Providers [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Mar19]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html

  3. Korean Society of Infectious Diseases; Korean Society of Pediatric Infectious Diseases; Korean Society of Epidemiology; Korean Society for Antimicrobial Therapy; Korean Society for Healthcare-associated Infection Control and Prevention; Korea Centers for Disease Control and Prevention. Report on the epidemiological features of coronavirus disease 2019 (COVID-19) outbreak in the Republic of Korea from January 19 to March 2, 2020. J Korean Med Sci 2020;35(10):e112.

  4. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020 February 24 (Epub ahead of print)

  5. Epidemiological Characteristics of 2143 Pediatric Patients ... [Internet]. [cited 2020Mar20]. Available from: https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf

  6. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) - United States, February 12–March 16, 2020 [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Apr7]. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm

  7. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults [published online ahead of print, 2020 Mar 23]. Acta Paediatr. 2020;10.1111/apa.15270. doi:10.1111/apa.15270

  8. Jiatong S, Lanqin L, Wenjun L. COVID-19 epidemic: disease characteristics in children [published online ahead of print, 2020 Mar 31]. J Med Virol. 2020;10.1002/jmv.25807. doi:10.1002/jmv.25807

  9. Lougheed MD, Leniere C, Ducharme FM, et al. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults; Executive summary. Can Respir J 2012;19(6):e81-8.

Multi-system Inflammatory Syndrome in Children with COVID-19 (Kawasaki-Like Illness)

  • Recent reports from Europe and North America have described clusters of children and adolescents requiring ICU admission with a multisystem inflammatory condition with features similar to those of Kawasaki disease and toxic shock syndrome 

  • An Italian observational cohort study published on May 13th in the Lancet, reported a 30-fold increased incidence of Kawasaki-like disease in the months of March-April 2020 [8]

    • Children diagnosed with Kawasaki-like disease after the SARS-CoV-2 epidemic began showed evidence of immune response to the coronavirus; these children were older, had a higher rate of cardiac involvement, and features of macrophage activation syndrome. 

    • The SARS-CoV-2 epidemic was associated with high incidence of a severe form of Kawasaki disease

  • These case reports and small series have described a presentation of acute illness accompanied by a hyperinflammatory syndrome, leading to multiorgan failure and shock [4-6]

    • Initial hypotheses are that this syndrome may be related to COVID-19 based on initial laboratory testing showing positive serology in a majority of patients 

      • some patients with this presentation were COVID-19 negative on serology but had known exposure 

    • Children presenting with this syndrome were treated with antibiotics, anti-inflammatories, including aspirin, IVIG and steroids, however no conclusions about treatment can be drawn from the current studies.

    • From these studies, 1 pediatric death was recorded due to this syndrome; this child did test SARS-CoV2 positive post-mortem [4]

 

Further data describing this clinical presentation, including the severity, outcomes and epidemiology is needed

 

  • Using the preliminary reports on clinical and laboratory features observed in children to date the WHO has developed a preliminary definition for this presentation: multisystem inflammatory disorder in children and adolescents [7]

  • A similar case definition by the CDC was also released [9]

  • Treatment recommendations presently center around treating with IVIG and aspirin for those who meet diagnostic criteria for Kawasaki disease, and IVIG for those who meet criteria for toxic shock syndrome.

Preliminary case definition [7]

Children and adolescents 0–19 years of age with fever >3 days AND two of the following:      

                                            

  1. Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet).

  2. Hypotension or shock.

  3. Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP),

  4. Evidence of coagulopathy (by PT, PTT, elevated d-Dimers).

  5. Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain)

AND

 

Elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin. 

AND

No other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes.

AND

 

Evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19.

References

  1. Shekerdemian LS, Mahmood NR, Wolfe KK, Riggs BJ, Ross CE, McKiernan CA, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. 2020. Epub 2020/05/12

  2. Kamali Aghdam M, Jafari N, Eftekhari K. Novel coronavirus in a 15-day-old neonate with clinical signs of sepsis, a case report. Infect Dis (Lond). 2020;52(6):427-9. Epub 2020/04/03

  3. Team CC-R. Coronavirus Disease 2019 in Children - United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(14):422-6. Epub 2020/04/10

  4. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020. Epub 2020/05/11.

  5. DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, et al. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. J Pediatr. 2020

  6. Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Bradley Segal J, et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr. 2020. Epub 2020/04/09

  7. World Health Organization, Scientific Brief - Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19, May 15th, 2020, https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19

  8. Verdoni, L., Mazza, A., et al., An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. The Lancet. May 13, 2020. DOI:https://doi.org/10.1016/S0140-6736(20)31103-X

  9. CDC Health Alert Network: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). Accessed May 15, 2020.

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