COVID-19 Intelligence Report: Pediatrics

Updates on obstetric, pediatric, inflammatory, and severe disease complications: 

• ​In children presenting with COVID-19, co-infection with other respiratory pathogens may be common (51% of 74 pediatric patients had 1 or more co-pathogen; 42% had 2 or more co-pathogens). 
• Evidence on PIMS or MIS-C continues to build, with 58 cases reported from the UK and 156 from France. In one report of 21 patients in Paris, there was a possible association with African ancestry. 
• Cardiac findings in patients with MIS-C in NY included ST/T-wave abnormalities, dysrhythmias (PVCs, NSVT, sinus bradycardia), and ventricular dysfunction. These may warrant long-term monitoring. 

Title: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19)

Publisher: CDC Health Alert Network

Publication Date: May 14, 2020

URL: https://emergency.cdc.gov/han/2020/han00432.asp?fbclid=IwAR0uAXSaCVsqwUgU1gddCE96m2a-Or31Zhxx9GD0WlDAgF0GGcYJuNfH_N0

Key Takeaway:  Centers for Disease Control and Prevention (CDC) issued a Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C):

•An individual aged <21 years presenting with fever (i), laboratory evidence of inflammation (ii), and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND

•No alternative plausible diagnoses; AND

•Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms:

i Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours

ii Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin

 

Additional comments

•Some individuals may fulfill full or partial criteria for Kawasaki disease but should be reported if they meet the case definition for MIS-C

•Consider MIS-C in any pediatric death with evidence of SARS-CoV-2 infection

CDC recommends healthcare providers report any patient who meets the case definition to local, state, and territorial health departments to enhance knowledge of risk factors, pathogenesis, clinical course, and treatment of this syndrome.

 

Title: An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: An observational cohort study

Publisher: The Lancet

Publication Date: May 13, 2020

URL: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31103-X/fulltext?fbclid=IwAR3FTBsNWiH600V6V1ByqDS1qBRyfKcNgRbofhbW0ytMu-xye0U6As9ig2g

Key Takeaway:  This reports a 30-fold increased incidence of Kawasaki-like disease in Italy. Children diagnosed after the SARS-CoV-2 epidemic who showed evidence of immune response to the virus were older, had a higher rate of cardiac involvement, and features of macrophage activation syndrome.  The authors suggest similar outbreak of Kawasaki-like disease is expected in countries involved in the SARS-CoV-2 epidemic.

 

Title: Outbreak of Kawasaki disease in children during COVID-19 pandemic: A prospective observational study in Paris, France. ****Preprint**** 

Publisher: medrXiv

Publication Date: May 14, 2020

URL: https://www.medrxiv.org/content/10.1101/2020.05.10.20097394v1

Key Takeaway: Not peer-reviewed. This study is currently the largest cohort reported on these cases in which the diagnosis of Kawasaki disease (KD) was based on the criteria of the American Heart Association for complete and incomplete KD and the criteria proposed by Kanegaye et al. were used for the diagnosis of KD shock syndrome (KDSS). A total of 17 children were admitted for KD over an 11-day period. Eleven patients presented with KDSS requiring intensive care support, and 12 had myocarditis. All children had marked gastrointestinal symptoms at the early stage of illness and high levels of inflammatory markers. Fourteen patients (82%) had evidence of recent SARS-CoV-2 infection (positive RT-PCR 7/17, positive IgG antibody detection 14/16). All patients received immunoglobulins and some received corticosteroids (5/17). The clinical outcome was favorable in all patients.

•  Compared to past descriptions of Kawasaki disease, this cohort had an 8-fold increase in procalcitonin level, what suggests a particularly strong post-viral immunological reaction to SARS-CoV-2 as compared with other viral agents.
•  59% of the patients were originally from sub-Saharan Africa or Caribbean islands, and 12% from Asia, suggesting possible genetic predisposition or travel-associated exposure.

 

Title: Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic

Publisher: Circulation

Publication Date: May 17, 2020

URL: https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.120.048360

Key Takeaway: Authors report a series of febrile pediatric patients with acute heart failure potentially associated with SARS-CoV-2 infection and the multisystem inflammatory syndrome in children (MIS-C) as defined by the US Centers for Disease Control. Children may experience an acute cardiac decompensation due to severe inflammatory state following SARS-CoV-2 infection (multisystem inflammatory syndrome in children - MIS-C). Treatment with immune globulin appears to be associated with recovery of left ventricular systolic function.

Title: Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units

Publisher: JAMA Pediatrics

Publication Date: May 11, 2020

URL: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037  

Key Takeaway:  Cross-sectional study of 46 North American PICUs, from March 14-April 3, 2020 found 48 children were admitted to 14 PICUs in the US, 0 in Canada. 40 children (83%) had at least 1 pre-existing medical condition, 35 (73%) presented with respiratory symptoms, and 18 (38%) required invasive ventilation. 11 patients (23%) had 2-or more organ failure. By April 10, 2020, mortality rate was 4.2% (2 patients), with 15 still hospitalized, and 3 on ventilatory support, and 1 receiving ECMO. Children can have severe infection though far less frequently than adults.

 

Title: Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region

Publisher: Journal of Pediatrics

Publication Date: May 13, 2020

URL: https://www.jpeds.com/article/S0022-3476(20)30581-3/pdf

Key Takeaway:  GW-affiliated author. Journal pre-proof of retrospective cohort study of 177 COVID+ children and young adults with clinical symptoms treated at the Children’s National Hospital. 44/177 required hospitalization of which 9 were critically ill, median age of critically ill patients compared to non-critically ill patients was significantly higher (17.3 vs 3.6 years, p=0.04). Children <1 year old and young adults >15 years old together accounted for 64% of hospitalizations. Asthma was the most frequent underlying comorbidity overall, however neurologic disorders, cardiac, hematologic, and oncologic disorders were significantly more common in hospitalized patients compared to non-hospitalized patients. No underlying health problem was identified in 16/44 (37%) hospitalized patients and 2/9 critically ill patients. No deaths reported thus far.

 

Title: Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020

Publisher: CDC / MMWR

Publication Date: May 8, 2020

URL: https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm

Key Takeaway:  Observational report examining vaccine tracking data shows declines vaccination after national emergency declared on March 13, 2020, though less so measles- vaccine doses for children <24 months. It will be important to remind patients to continue routine vaccinations to prevent vaccine-preventable disease outbreaks in setting of COVID.

Title: Health notice for District of Columbia Health Care Providers: Interim Guidance Regarding Pediatric Multi-System Inflammatory Syndrome Possibly Associated with COVID-19

Publisher: District of Columbia Department of Health

Publication Date: 11 May 2020

URL: https://content.govdelivery.com/attachments/DCWASH/2020/05/11/file_attachments/1448094/COVID_Peds%20Inflamm%20Disease_5-8-2020_FINAL.PDF

Key Takeaway:  There is a growing concern over a number of children in the United States and United Kingdom who have presented with a systemic inflammatory disease similar in many ways to Kawasaki’s Disease, and thought to perhaps be associated with COVID infection.  Some have required significant intensive care, including the one case in the District.  Not all children have tested positive for COVID.  A standard case definition has been established.  Suspected cases are a mandatory report in the District of Columbia.

 

Title: Chilblains-like Lesions in Children Following Suspected Covid-19 Infection

Publisher: Pediatric Dermatology / Wiley

Publication Date: 06 May 2020

URL: https://onlinelibrary.wiley.com/doi/abs/10.1111/pde.14210

Key Takeaways: Chilblains are erythrocyanotic macular or papular skin lesions that are typically associated with cold exposure. This case series highlights four children in Italy who presented with chilblain-like skin findings before or upon developing other any symptoms of COVID.  Pediatric patient presenting with skin lesions such as this may need further evaluation for COVID and its associated thromboembolic complications.

URL: https://pediatrics.aappublications.org/content/early/2020/03/16/peds.2020-0702.1 

Key Takeaway: 

• Children at all ages appeared susceptible to COVID-19, and there was no significant gender difference. Over 90% had asymptomatic, mild, or moderate disease.  The number of fatalities has been extremely low. 

 

Title:  Ventilator Simulator for Pediatrics 

Publisher: Open Pediatrics

Publication: April 2020

URL: https://www.openpediatrics.org/simulators 

Key Takeaway: 

• This is a free simulator for training on ventilator management in pediatric patients.