Pediatrics

Inpatient pediatrics management

CDC Data shows prevalence of symptoms among adults and peds:

Signs and symptoms among 291 pediatric (age <18 years) and 10,944 adult (age 18–64 years) patients with laboratory-confirmed COVID-19 — United States, February 12–April 2, 2020

Like adults, the three most common symptoms of SARS-CoV-2 in patients ages 0-18 are fever, cough, and shortness of breath. However, while at least one of these three symptoms were reported in 93% of patients 18-64 years, this was only true for 73% of pediatric patients.

Hospitalized vs. Non-Hospitalized Patients 

A retrospective cohort study from Children's National noted that shortness of breath was more common in the hospitalized cohort (11/44, 26%) compared with non-hospitalized patients (16/133, 12%, p=0.04.). Conversely, less severe respiratory symptoms such as sore threat, congestion (p=0.004), cough (p=0.004), and headache (p=0.01) were common in the non-hospitalized cohort. 

List of References

COVID C, COVID C, COVID C, Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T. Coronavirus Disease 2019 in Children—United States, February 12–April 2, 2020. Morbidity and Mortality Weekly Report. 2020 Apr 10;69(14):422.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics. 2020 May 13.

Last Updated 4 months ago
  • Data from the CDC suggests that pediatrics makes 1.7% of total COVID-19 cases in United States (0-18yrs)
  • Median age of pediatric patients was determined to be 11 years.
    • In China, one study of 2135 pediatric patients determined median age 7 years.

Sources:

Castagnoli R, Votto M, Licari A, Brambilla I, Bruno R, Perlini S, Rovida F, Baldanti F, Marseglia GL. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA pediatrics. 2020 Apr 22.

COVID C, COVID C, COVID C, Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T. Coronavirus Disease 2019 in Children—United States, February 12–April 2, 2020. Morbidity and Mortality Weekly Report. 2020 Apr 10;69(14):422.

Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, Tong S. Epidemiology of COVID-19 among children in China. Pediatrics. 2020 Apr 1.

Surveillances V. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly. 2020;2(8):113-22.

 

Last Updated 4 months ago
  • Young age was determined to be a risk factor for severity:
    •  10.6% of infants <1 year of age were severe or critical 
    • 3.0% for the 16-19 year were severe or critical
  • CDC Data <18 year hospitalization 6 to 20 percent and ICU admission 0.58 to 2 percent. 

Data from a retrospective cohort study at Children's National revealed the following age distribution of SARS-CoV2 cases  

Analysis specifically showed that 

  • Infants and patients >15 years of age were over-represented among hospitalized patients (P =0.07)
  • Patients >15 years were represented at higher rates among critically ill cases (P =0.02)

Sources:

Castagnoli R, Votto M, Licari A, Brambilla I, Bruno R, Perlini S, Rovida F, Baldanti F, Marseglia GL. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA pediatrics. 2020 Apr 22.

COVID C, COVID C, COVID C, Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T. Coronavirus Disease 2019 in Children—United States, February 12–April 2, 2020. Morbidity and Mortality Weekly Report. 2020 Apr 10;69(14):422.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics. 2020 May 13.

Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, Tong S. Epidemiology of COVID-19 among children in China. Pediatrics. 2020 Apr 1.

Last Updated 4 months ago

According to the CDC, children who fall under the following categories are at increased risk of severe illness from COVID-19 compared to other children: 

  • Congenital heart disease 
  • Neurologic conditions 
  • Metabolic conditions
  • Genetic conditions
  • Medically complex 

Data from a cohort study from Children's National Hospital estimated that 39% of patients admitted with SARS-CoV2 had an underlying health condition. Data showed that patients with comorbidities were more likely to be hospitalized: 

Percents represent 27/44 patients in the hospitalized cohort and  42/133 patients in the non-hospitalized cohort (p=-.001) 

The most common condition was asthma (in 20% of patients). However, it was not associated with increased risk of hospital or critical care admission. The following sets of conditions were common in hospitalized patients compared to non-hospitalized:

  • Neurological (19%; p<0.0001)
  • Cardiac (p=0.004)
  • Hematologic (p=0.004)  
  • Oncologic (p=0.013)

PICU 

In a study on 48 PICU patients with COVID-19, an estimated 83% had at least one significant comorbidity.

Sources:

Covid CD, COVID C, COVID C, Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T. Coronavirus Disease 2019 in Children—United States, February 12–April 2, 2020. Morbidity and Mortality Weekly Report. 2020 Apr 10;69(14):422.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics. 2020 May 13.

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 Pediatrics. 2020May11 [cited 2020May12]; Available from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037

Last Updated 3 months ago

In a case series of 2135 children from China that included 728 cases of confirmed COVID-19, the distribution of severity is determined to be as follows: 

Data from Children's National on 177 patients noted the following distribution (by age) of SARS-CoV2 patients:

A total of 44 hospitalized patients (non critically ill N=35, critically ill N=9) 

It is important to note that no deaths were noted in any of that patients (at the time of publication).

PICU 

A study on 46 pediatric hospitals in North America noted that only 35% had at least one COVID-19 related admission to the PICU. 

Of the 48 patients included in the study, the median length of stay in the PICU was 5 days. The outcomes at follow up were: 

Patients admitted between March 14 and April 3, 2020 with follow-up to April 10, 2020. Of still hospitalized patients, 9 (19%) were in severe or critical condition while 6 (13%) were in mild or moderate condition. 

List of References 

Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, Tong S. Epidemiology of COVID-19 among children in China. Pediatrics. 2020 Apr 1.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics. 2020 May 13.

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 Pediatrics [Internet]. 2020May11; Available from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037

 

Last Updated 4 months ago

Data on laboratory biomarkers in COVID-19 positive pediatric patients hasn’t been researched extensively. A case study noted that 64% of pediatric patients had an elevated procalcitonin (>46 pg/ml) and 20% had an elevated C-reactive protein (>10 mg/L).

List of References 

Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, Zhang W, Wang Y, Bao S, Li Y, Wu C. SARS-CoV-2 infection in children. New England Journal of Medicine. 2020 Mar 18.

Last Updated 4 months ago

In a systematic review of 18 studies in China, key radiologic features in both symptomatic and asymptomatic patients with laboratory-confirmed COVID-19 included bronchial thickening (described in 4 articles) and ground glass opacities (described in 3 articles).

case series of 171 patients with SARS-CoV2 infection, the four most common findings on chest CT were

Research suggests that radiographic findings may be present in asymptomatic patients.

List of References 

Castagnoli R, Votto M, Licari A, Brambilla I, Bruno R, Perlini S, Rovida F, Baldanti F, Marseglia GL. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA pediatrics. 2020 Apr 22. 

Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, Zhang W, Wang Y, Bao S, Li Y, Wu C. SARS-CoV-2 infection in children. New England Journal of Medicine. 2020 Mar 18.

Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, Ma H, Chen W, Lin Y, Zheng Y, Wang J. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Science China Life Sciences. 2020 Mar 4:1-6.

Last Updated 4 months ago

Use of Antimicrobials

The majority of COVID-19 cases among children are asymptomatic or mild and thus do not require hospitalization. Per multicenter guidance, children with COVID-19 with severe or critical lower respiratory tract infection typically require admission to hospital. 

Antivirals can be considered in severe and critically ill patients. If used, multicenter guidance recommends the following: 

  • Remdesivir as the first line antiviral, preferably used as part of a clinical trial
  • Hydroxychloquine if Remdesivir is unsuitable or unavailable; dosing regimen should include a loading dose on day 1 and a duration of 5 days or fewer
  • The panel was split the use of lopinavir-ritonavir in pediatric patients with COVID-19
  • Recommend against combination therapy with lopinavir-ritonavir and ribavirin.

Seattle Children’s Hospital adapted treatment algorithms from UW for pediatric patients with confirmed COVID-19.

Antimicrobial Dosing

Dosing for Remdesivir and Hydroxychloroquine based on adult pharmacokinetic models is as follows:

Respiratory Support

Of 48 patients admitted to PICUs in the USA, the following levels of maximum respiratory support were needed during their stay:

Among 9 critically ill patients at Children's national, 8 out of 9 needed respiratory report. Four specifically required mechanical ventilation. 

List of References

Chiotos K, Hayes M, Kimberlin DW, Jones SB, James SH, Pinninti SG, Yarbrough A, Abzug MJ, MacBrayne CE, Soma VL, Dulek DE. Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2. Journal of the Pediatric Infectious Diseases Society. 2020 Apr 22.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics. 2020 May 13.

Maharaj AR, Wu H, Hornik CP, Balevic SJ, Hornik CD, Smith PB, Gonzalez D, Zimmerman KO, Benjamin DK, Cohen-Wolkowiez M. Simulated Assessment of Pharmacokinetically Guided Dosing for Investigational Treatments of Pediatric Patients With Coronavirus Disease 2019. JAMA Pediatrics. 2020 Jun 5:e202422-.

Seattle Children's Provider News [Internet]. Seattle Childrens Provider News RSS. [cited 2020 May 1]. Available from: https://providernews.seattlechildrens.org/provider-faqs-covid-19/

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 Pediatrics. 2020May11 [cited 2020May12]; Available from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037

Last Updated 3 months ago

The Children’s Hospital of Philadelphia developed a series of clinical pathways for pediatric populations in the inpatientemergency, and ambulatory settings. Additionally, Children’s National Hospital provided triage screening guidelines for call centers and nurses. 

Data from an observational retrospective cohort study from Children's National estimated that 9.8% (177/1804) of symptomatic children and young adults tested for SARS-CoV2 were positive. However, because children infected with COVID-19 typically have less severe cases, they tend to be tested less frequently. Thus, it is harder to determine the true infectivity rate of this population. 

List of References 

Coronavirus (COVID-19) Provider Resources: Children's National Hospital [cited 2020 May 1]. Available from: https://childrensnational.org/healthcare-providers/refer-a-patient/covid

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, Ansusinha E, Hahn A, Hamdy R, Harik N, Hanisch B. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics. 2020 May 13.

Seattle Children's Provider News [Internet]. Seattle Childrens Provider News RSS. [cited 2020 May 1]. Available from: https://providernews.seattlechildrens.org/provider-faqs-covid-19/

Last Updated 4 months ago
  • According, to the latest update from the American College of Obstetricians and Gynecologists (ACOG) on May 19, 2020, facilities may consider temporarily separating COVID+ patients or PUIs from their newborns until the patient's isolation precautions are discontinued.
  • The decision of separation of newborns from COVID+ patients or PUI mothers should be made on a case-by-case basis between the patients and their clinical team. Some of the risks of separation of patients from their newborns include stress and disruption of breastfeeding.

Source:

American College of Obstetricians and Gynecologists (ACOG). Novel Coronavirus 2019 (COVID-19): Practice Advisory. 2020May19. Available from: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019

Last Updated 4 months ago
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