COVID-19 associated pediatric complications

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Harmeet Kharoud M.D.[2]; Abdelrahman Ibrahim Abushouk, MD[3]

Presentations

• Presentation of COVID-19 is less severe in children as compared to adults.
• According to CDC, as of April 2, 2020, 1.7% confirmed cases of COVID-19 were reported in children aged <18 years age among the total number of confirmed cases of COVID-19.
• Illness severity of COVID-19 in children ranges from asymptomatic to critical.

Symptoms

• Fever and Cough are one of the most common symptoms reported in children. One study showed fever is prevalent in 47.5% of children and cough in 41.5% among the 1124 children with COVID-19.According to the CDC, fever, and cough was reported in 56% and 54% of children with COVID 19
• Dyspnea, nasal congestion, pharyngeal erythema, and sore throat are also common presentations in children.
• Gastrointestinal symptoms-The gastrointestinal manifestation in COVID-19 positive children are diarrhea, vomiting, abdominal pain, nausea, and anorexia. Children can present with gastrointestinal symptoms in the absence of respiratory symptoms.
• Cutaneous Findings

Clinical Course of COVID-19 in children.

• Asymptomatic presentation-
  • Children present with no clinical signs or symptoms with normal chest imaging.
  • Among 2143 children with COVID-19 infection 4% of children were asymptomatic.
  • According to one study 14.2% of children were asymptomatic. Another study showed 18% of asymptomatic children with COVID-19.
• Mild Disease
  • Children present with mild symptoms including fever, fatigue, myalgia, cough.
  • Among 2143 children with COVID-19 infection 51% of children had a mild disease of COVID-19.
  • A study showed 36.3% of children present with a mild form of the disease.
• Severe
  • Children present with dyspnea, central cyanosis, hypoxia.
  • Among 2143 children with COVID-19 infection 5% of children had a severe presentation.
  • 2.1% of children present with a severe form of COVID-19 disease.
  • Children with underlying comorbidities are more susceptible to getting severe COVID-19 disease.
• Critical
  • Children present with acute respiratory distress syndrome(ARDS), respiratory failure, shock, or multi-organ dysfunction.
  • Among 2143 children with COVID-19 infection, 0.6%% of children had a critical presentation.

Complications

Some of the complications associated with COVID-19 pediatric population are

• Multisystem Inflammatory Syndrome in Children (MISC-C)
• Exacerbation of the underlying conditions
• Sepsis
• Septic shock
• Secondary Bacterial infections.

Multisystem Inflammatory Syndrome in Children (MIS-C)

• It is a condition that causes inflammation of some parts of the body like heart, blood vessels, kidneys, digestive system, brain, skin, or eyes.
• According to recent evidence it is suggested that children with MISC had antibodies against COVID-19 suggesting children had COVID-19 infection in the past.

Symptoms

• Fever lasting 24 hours or longer.
• Vomiting
• Diarrhea
• Abdominal pain
• Skin rash
• Red eyes
• Redness or swelling of the lips and tongue
• Lethargy
• Redness or swelling of the hands or feet

Emergency Warning Signs

• Difficulty Breathing
• Chest pain
• New onset confusion
• Lethargy
• Cyanosis
• Abdominal pain

Diagnosis

Preliminary WHO case definition: 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 (diarrhea, 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
• Leucocytosis(7.5%) or Leucopenia(16.6%)
• Increased (27.4%) or decreased (24%) neutrophils
• Lymphopenia (12.9%) or Lymphocytosis (11.7%)
• Increased (9.5%) or decreased (3.2%) platelets
• Increased CRP levels (19.3%)
• Increased procalcitonin levels (49.8%)
• Increased liver enzymes (19.2%)
• Increased Serum Creatinine (4%)
• Increased blood urea nitrogen (5%)
• Increased lactate dehydrogenase (LDH) levels (29%)
• Increased Creatine kinase levels (21%)
• Increased D-dimer levels (12%)

Co-infections

Co-infection with other pathogens were reported in 27% of cases. Some common microorganisms associated with SARS-CoV-2 infection in children are:

• Mycoplasma pneumoniae
• Influenza B virus
• Influenza A virus
• Respiratory syncytial virus (RSV)
• Cytomegalovirus (CMV)
• Enterobacter aerogenes

Radiological findings

CT chest is an important diagnostic modality in pediatric patients with COVID-19. Chest CT scans has reportedly shown higher positive rates in suspected patients than RT-PCR. It has better sensitivity. CT chest and a series of chest X-rays can be used to monitor the progression of the disease. Imaging findings reported in the studies are

• Local patchy shadows (18.7%)
• Bilateral patchy shadows (12.3%)
• Consolidation (33%)
• Ground glass opacities (28%)
• Interstitial abnormalities (1.2%)
• Pleural effusion was reported in a 2-month old child who had a co-infection with RSV along with SARS-CoV-2

Children are at increased risk of radiation and its effects, so CT scans and X-rays should be judiciously used in them. It is advised to perform Pulmonary Ultrasonography (USG) in newborns. It has better sensitivity and is safer than CT scans and Chest X-rays.