Severe and fatal forms of COVID-19 in children

Plans to Vaccinate Children for Coronavirus Disease 2019: A Survey of United States Parents

In a national survey of 2074 US parents of children ≤12 years of age conducted in March 2021, 49.4% reported plans to vaccinate their child for coronavirus disease 2019 when available. Lower income and less education were associated with greater parental vaccine hesitancy/resistance; safety and lack of need were primary reasons for vaccine hesitancy/resistance.

Neurological Effects of COVID-19 in Children

The COVID-19 pandemic has spread rapidly across the world in 2020, affecting both adults and, to a lesser extent, children. In this article, the authors describe the neurologic manifestations of COVID-19 in children, including the epidemiology, pathogenesis, clinical features, laboratory and imaging findings, and treatment options. The management of patients with concomitant neuroimmunologic disorders and drug interactions between medications used to treat COVID-19 and other neurologic disorders (especially immune-modifying drugs) is also discussed.

Seizures as the main presenting manifestation of acute SARS-CoV-2 infection in children

Objectives

To explore the rate, characteristics, risk factors, and prognosis of children presenting with seizures as the main symptom of acute COVID-19 (coronavirus disease 2019).

Methods

We conducted a systematic retrospective study to identify all children who presented to the emergency departments of a tertiary academic medical center between March 1st and December 31st 2020 and had a SARS-CoV-2 infection based on RT-PCR (reverse transcription-polymerase chain reaction) from nasopharyngeal swab. Clinical and demographic data were extracted from the electronic medical records and reviewed.

Results

Total of 175 children were diagnosed with acute SARS-CoV-2 infection in the emergency departments during the study period. Of those, 11 presented with seizures. Age ranged from six months to 17 years and 4 were girls. Five presented with status epilepticus and responded to loading doses of anti-seizure medications. Six had fever. Seven had prior history of neurological disorder. Full recovery was the rule.

Significance

Unlike in adults, seizures occur early and may be the main manifestation of acute COVID-19 in children. Seizures, including status epilepticus, may occur without fever even in children with no history of epilepsy and are not associated with severe disease. A high index of suspicion is required for early diagnosis thus infection control measures can be taken.

A Systematic Review of Characteristics Associated with COVID-19 in Children with Typical Presentation and with Multisystem Inflammatory Syndrome

Setting off a global pandemic, coronavirus disease 2019 (COVID-19) has been marked by a heterogeneous clinical presentation that runs the gamut from asymptomatic to severe and fatal. Although less lethal in children than adults, COVID-19 has nonetheless afflicted the pediatric population. This systematic review used clinical information from published literature to assess the spectrum of COVID-19 presentation in children, with special emphasis on characteristics associated with multisystem inflammatory syndrome (MIS-C). An electronic literature search for English and Chinese language articles in COVIDSeer, MEDLINE, and PubMed from 1 January 2020 through 1 March 2021 returned 579 records, of which 54 were included for full evaluation. Out of the total 4811 patients, 543 (11.29%) exhibited MIS-C. The most common symptoms across all children were fever and sore throat. Children presenting with MIS-C were less likely to exhibit sore throat and respiratory symptoms (i.e., cough, shortness of breath) compared to children without MIS-C. Inflammatory (e.g., rash, fever, and weakness) and gastrointestinal (e.g., nausea/vomiting and diarrhea) symptoms were present to a greater extent in children with both COVID-19 and MIS-C, suggesting that children testing positive for COVID-19 and exhibiting such symptoms should be evaluated for MIS-C.

Diabetes Insipidus Complicating Management in a Child with COVID-19 and Multiorgan System Failure: A Novel Use for Furosemide

Judicious balance of fluids is needed for optimal management of acute respiratory distress syndrome (ARDS). Achieving optimal fluid balance is difficult in patients with disorders of fluid homeostasis such as diabetes insipidus (DI). There is little data on the use of Furosemide to aid in balancing fluid and electrolytes in patients with DI. Here, we present a critically ill 11-year-old female with developmental delay, septo-optic dysplasia, central DI, and respiratory failure secondary to COVID-19 ARDS. She required careful titration of a Vasopressin infusion in addition to IV Furosemide for successful management of fluid and electrolyte derangements. On admission, she demonstrated high-volume urine output with mild hypernatremia (serum sodium 156 mmol/L). Despite her maximum Vasopressin infusion rate of 8 mU/kg/hr, by day two of admission, she voided a total of 4 L resulting in severe hypernatremia (serum sodium 171 mmol/L). With continually high Vasopressin infusion rates, her overall fluid balance became increasingly net positive, although her hypernatremia persisted. Her ARDS continued to worsen. After 48 hours of the addition of intermittent Furosemide, successful diuresis along with resolution of hypernatremia was achieved. The combination of IV Furosemide with Vasopressin infusion resulted in tailored diuresis and more controlled titration of serum sodium levels than adjustment in Vasopressin and fluids alone. These results are in contradistinction to the published literature, which focuses on the use of thiazide diuretics in managing DI. This experience highlights the potential for loop diuretics to aid in establishing a desired fluid and electrolyte status in managing patients with both DI and ARDS.

Children with SARS-CoV-2 in the National COVID Cohort Collaborative (N3C)

IMPORTANCE

SARS-CoV-2.

OBJECTIVE

To determine the characteristics, changes over time, outcomes, and severity risk factors of SARS-CoV-2 affected children within the National COVID Cohort Collaborative (N3C).

DESIGN

Prospective cohort study of patient encounters with end dates before May 27th, 2021.

SETTING

45 N3C institutions.

PARTICIPANTS

Children <19-years-old at initial SARS-CoV-2 testing.

MAIN OUTCOMES AND MEASURES

Case incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs MIS-C contrasts for children infected with SARS-CoV-2.

RESULTS

728,047 children in the N3C were tested for SARS-CoV-2; of these, 91,865 (12.6%) were positive. Among the 5,213 (6%) hospitalized children, 685 (13%) met criteria for severe disease: mechanical ventilation (7%), vasopressor/inotropic support (7%), ECMO (0.6%), or death/discharge to hospice (1.1%). Male gender, African American race, older age, and several pediatric complex chronic condition (PCCC) subcategories were associated with higher clinical severity (p ≤ 0.05). Vital signs (all p≤0.002) and many laboratory tests from the first day of hospitalization were predictive of peak disease severity. Children with severe (vs moderate) disease were more likely to receive antimicrobials (71% vs 32%, p<0.001) and immunomodulatory medications (53% vs 16%, p<0.001). Compared to those with acute COVID-19, children with MIS-C were more likely to be male, Black/African American, 1-to-12-years-old, and less likely to have asthma, diabetes, or a PCCC (p < 0.04). MIS-C cases demonstrated a more inflammatory laboratory profile and more severe clinical phenotype with higher rates of invasive ventilation (12% vs 6%) and need for vasoactive-inotropic support (31% vs 6%) compared to acute COVID-19 cases, respectively (p<0.03).

CONCLUSIONS

In the largest U.S. SARS-CoV-2-positive pediatric cohort to date, we observed differences in demographics, pre-existing comorbidities, and initial vital sign and laboratory test values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission. Further work is needed to translate this knowledge into improved outcomes.

Children's role in the COVID-19 pandemic: a systematic review of early surveillance data on susceptibility, severity, and transmissibility

SARS-CoV-2 infections have been reported in all age groups including infants, children, and adolescents. However, the role of children in the COVID-19 pandemic is still uncertain. This systematic review of early studies synthesises evidence on the susceptibility of children to SARS-CoV-2 infection, the severity and clinical outcomes in children with SARS-CoV-2 infection, and the transmissibility of SARS-CoV-2 by children in the initial phases of the COVID-19 pandemic. A systematic literature review was conducted in PubMed. Reviewers extracted data from relevant, peer-reviewed studies published up to July 4th 2020 during the first wave of the SARS-CoV-2 outbreak using a standardised form and assessed quality using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. For studies included in the meta-analysis, we used a random effects model to calculate pooled estimates of the proportion of children considered asymptomatic or in a severe or critical state. We identified 2775 potential studies of which 128 studies met our inclusion criteria; data were extracted from 99, which were then quality assessed. Finally, 29 studies were considered for the meta-analysis that included information of symptoms and/or severity, these were further assessed based on patient recruitment. Our pooled estimate of the proportion of test positive children who were asymptomatic was 21.1% (95% CI: 14.0-28.1%), based on 13 included studies, and the proportion of children with severe or critical symptoms was 3.8% (95% CI: 1.5-6.0%), based on 14 included studies. We did not identify any studies designed to assess transmissibility in children and found that susceptibility to infection in children was highly variable across studies. Children's susceptibility to infection and onward transmissibility relative to adults is still unclear and varied widely between studies. However, it is evident that most children experience clinically mild disease or remain asymptomatically infected. More comprehensive contact-tracing studies combined with serosurveys are needed to quantify children's transmissibility relative to adults. With children back in schools, testing regimes and study protocols that will allow us to better understand the role of children in this pandemic are critical.

Neurological Complications of SARS-CoV-2 Infection in Children: A Systematic Review and Meta-Analysis

BACKGROUND

Knowledge about neurological complications of COVID-19 in children is limited due to the paucity of data in the existing literature. Some systematic reviews are available describing overall clinical features of COVID-19 in children and neurological complications of COVID-19 in adults. But to the best of our knowledge, no systematic review has been performed to determine neurological manifestations of COVID-19.

METHODS

Six different electronic databases (MEDLINE, EMBASE, Web of Science, CENTRAL, medRxiv and bioRxiv) were searched for articles related to COVID-19 and neurological complications in children. Studies/case series reporting neurological manifestations of COVID-19 in patients aged ≤18 years, as well as case reports, as neurological complications appear to be rare. The pooled estimate of various non-specific and specific neurological manifestations was performed using a random effect meta-analysis.

RESULTS

Twenty-one studies/case series and five case reports (3707 patients) fulfilled the eligibility criteria and were included in this systematic review, from a total of 460 records. Headache, myalgia and fatigue were predominant non-specific neurological manifestations, presenting altogether in 16.7% cases. Total of 42 children (1%) were found to have been reported with definite neurological complications, more in those suffering from a severe illness (encephalopathy-25, seizure-12, meningeal signs-17). Rare neurological complications were intracranial hemorrhage, cranial nerve palsy, Guillain-Barré syndrome and vision problems. All children with acute symptomatic seizures survived suggesting a favorable short-term prognosis.

CONCLUSION

Neurological complications are rare in children suffering from COVID-19. Still, these children are at risk of developing seizures and encephalopathy, more in those suffering from severe illness.

Clinical Profile and Risk Factors for Severe Disease in 402 Children Hospitalized with SARS-CoV-2 from India: Collaborative Indian Pediatric COVID Study Group

INTRODUCTION

There is a lack of large multicentric studies in children with COVID-19 from developing countries. We aimed to describe the clinical profile and risk factors for severe disease in children hospitalized with COVID-19 from India.

METHODS

In this multicentric retrospective study, we retrieved data related to demographic details, clinical features, including the severity of disease, laboratory investigations and outcome.

RESULTS

We included 402 children with a median (IQR) age of 7 (2-11) years. Fever was the most common symptom, present in 38.2% of children. About 44% had underlying comorbidity. The majority were asymptomatic (144, 35.8%) or mildly symptomatic (219, 54.5%). There were 39 (9.7%) moderate-severe cases and 13 (3.2%) deaths. The laboratory abnormalities included lymphopenia 25.4%, thrombocytopenia 22.1%, transaminitis 26.4%, low total serum protein 34.7%, low serum albumin 37.9% and low alkaline phosphatase 40%. Out of those who were tested, raised inflammatory markers were ferritin 58.9% (56/95), c-reactive protein 33.3% (41/123), procalcitonin 53.5% (46/86) and interleukin-6 (IL-6) 76%. The presence of fever, rash, vomiting, underlying comorbidity, increased total leucocyte count, thrombocytopenia, high urea, low total serum protein and raised c-reactive protein was factors associated with moderate to severe disease.

CONCLUSION

Fever was the commonest symptom. We identified additional laboratory abnormalities, namely lymphopenia, low total serum protein and albumin and low alkaline phosphatase. The majority of the children were asymptomatic or mildly symptomatic. We found high urea and low total serum protein as risk factors for moderate to severe disease for the first time.

Severe Coronavirus Disease Pneumonia in Pediatric Patients in a Referral Hospital

OBJECTIVE

We aimed to evaluate the characteristics and outcomes of critically ill children managed in an intensive care unit because of coronavirus disease (COVID-19) pneumonia with respiratory support requirements.

METHODS

We performed a single-center retrospective observational study in a pediatric intensive care unit (PICU) with 32 beds in Ankara City Hospital, Ankara, Turkey, from 13 March 2020 to 31 December 2020. Patients who needed positive-pressure ventilation (PPV) therapy for COVID-19 pneumonia were included in the study. Demographic, clinical and laboratory data were extracted from the patients' electronic medical records. As outcomes, the hospitalization rate of all pediatric patients diagnosed as having with COVID-19 by Polymerase Chaın Reactıon(PCR), PICU admission rate for COVID-19 pneumonia among all hospitalized patients, PPV support rate, intensive care hospitalization duration (days), total hospitalization duration (days), survival rate and tracheotomy requirement were evaluated.

RESULTS

During the study period, 7033 children tested positive for COVID-19 in PCR tests. Of these patients, 1219 were hospitalized for COVID-19. Seventeen patients needed PPV support because of COVID-19 pneumonia. High proportion (65%) of patients admitted to the PICU had comorbid diseases. Noninvasive ventilation was applied in 15 patients (88%). The hospitalization rate among the children with COVID-19 was 17%, of whom 1.6% were admitted to the PICU. Mortality rates were 0.056% of all the cases and 0.32% of the hospitalized patients in our hospital.

CONCLUSION

The presence of a comorbid disease could be a sign of severe disease in children with higher lethality. Very few children required PPV support because of severe COVID-19 pneumonia.

Definitive pathognomonic signs and symptoms of paediatric neurological COVID-19 are still emerging

Children with COVID-19 tend to show milder symptoms than adults during the pandemic, but growing evidence of neurological involvement has emerged. Some studies have reported neurological symptoms in children with COVID-19, which include multisystem inflammatory syndrome, a disease that shares some, but not all, of the characteristics of Kawasaki disease. This review presents, and discusses, the evidence to date. Our initial findings suggest that neurological manifestations can be considered to be the direct result of central nervous system viral invasion or post-infection immuno-mediated disease.

Severe acute respiratory syndrome coronavirus 2 infection and critically ill children

PURPOSE OF REVIEW

Amidst an ongoing pandemic, the delineation of the pediatric consequence of infection from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus is emerging. This review summarizes available pediatric data and covers the aspects of epidemiology, critical illness with acute infection [coronavirus disease 2019 (COVID-19)], the discovered multi-inflammatory syndrome in children (MIS-C), and management options.

RECENT FINDINGS

The available data from the source of the initial viral transmission and then through Europe, Africa, and the Western Hemisphere identifies important aspects of the SARS-CoV2 pandemic: 1) Pediatric infection occurs commonly, is likely underestimated, and transmission patterns remain incompletely described, 2) Pediatric patients suffer multiple end-organ injuries but COVID-19 is not the same prevalence in terms of severity as in adults, 3) MIS-C is a novel and life-threatening manifestation of exposure to the virus, 4) Management using a combination of supportive care, standard practice intensive care management, and anti-inflammatory agents is associated with recovery, 5) Long-term sequelae of viral exposure is unknown at this time.

SUMMARY

Emerging evidence suggests pediatric patients are at risk for severe and life-threatening effects of exposure to SARS-CoV2. As the pandemic continues, further research is warranted - particularly as a vaccine is not yet available for use in children.

Consensus recommendations for botulinum toxin injections in the spasticity management of children with cerebral palsy during COVID-19 outbreak

Spasticity is the most common motor disturbance in cerebral palsy (CP). Lockdown in the COVID-19 outbreak has profoundly changed daily routines, and similarly caused the suspension of spasticity treatment plans. Besides, the delay in botulinum toxin (BoNT) injection, which is important in the management of focal spasticity, led to some problems in children. This consensus report includes BoNT injection recommendations in the management of spasticity during the COVID-19 pandemic in children with CP. In order to develop the consensus report, physical medicine and rehabilitation (PMR) specialists experienced in the field of pediatric rehabilitation and BoNT injections were invited by Pediatric Rehabilitation Association. Items were prepared and adapted to the Delphi technique by PMR specialists. Then they were asked to the physicians experienced in BoNT injections (PMR specialist, pediatric orthopedists, and pediatric neurologists) or COVID-19 (pediatric infectious disease, adult infectious disease). In conclusion, the experts agree that conservative management approaches for spasticity may be the initial steps before BoNT injections. BoNT injections can be administered to children with CP with appropriate indications and with necessary precautions during the pandemic.

Risk Factors of Covid-19 Confirmed Died Patients in Dr. Kariadi Hospital: A Retrospective Study

Covid-19 is a communicable disease causing global pandemic. Some factors inflict worse infection. This study aims to investigate risk factors of Covid-19 confirmed died patients at Dr. Kariadi Hospital Semarang. It is a retrospective study with a total sample of all Covid-19 confirmed patients involving died and healed patients from March to June 2020. Data was gathered from screening forms and analysed with Chi Square (confidence interval of 95%). This study found sixteen risk factors of Covid-19 confirmed died patients involving age (p= 0.000; OR= 8.803; 95% CI 3.982-19.462), entrepreneur (p= 0.041; OR= 14.894; 95% CI 1.12-198.65), farmer/trader (p= 0.029; OR= 25.625; 95% CI 1.40-469.25), contact history (p= 0.000; OR= 12.923; 95% CI 6.163-27.097), fever (p= 0.000; OR= 4.877; 95% CI 2.647-8.984), dyspnea (p=0.000; OR= 17.018; 95% CI 8.523-33.977), cough (p= 0.009; OR= 2.178; 95% CI 1.205-3.935), lethargic (p=0.010; OR= 2.282; 95% CI 1.205-4.323), cold (p= 0.002; OR= 0.180; 95% CI 0.054-0.600), diabetes (p=0.000; OR= 9.767; 95% CI 3.932-24.263), COPD (p= 0.001; OR= 6.360; 95% CI 2.164-18.690), hypertension (p= 0.043; OR= 2.436; 95% CI 1.008-5.887), cancer (p=0.001; OR= 9.647; 95% CI 2.413-38.579), heart disease (p= 0.000; OR= 12.226; 95% CI 2.4-62.294), neurological disorders (p=0.008; OR= 6.057; 95% CI 1.650-22.232), and immune disorders (p=0.031; OR= 1.625; 95% CI 1.186-113.899). Adequate handling is needed to prevent death. in patients with confirmed Covid-19 who have risk factors.

Case Report: Cerebrovascular Events Associated With Bacterial and SARS-CoV-2 Infections in an Adolescent

Neurologic manifestations associated with Covid-19 are increasingly reported, especially stroke and acute cerebrovascular events. Beyond cardiovascular risk factors associated with age, some young adults without medical or cardiovascular history had stroke as a presenting feature of Covid-19. Suggested stroke mechanisms in this setting are inflammatory storm, subsequent hypercoagulability, and vasculitis. To date, a handful of pediatric stroke cases associated with Covid-19 have been reported, either with a cardioembolic mechanism or a focal cerebral arteriopathy. We report the case of an adolescent who presented with febrile meningism and stupor. Clinical, biological, and radiological features favored the diagnosis of Lemierre syndrome (LS), with Fusobacterium necrophorum infection (sphenoid sinusitis and meningitis) and intracranial vasculitis. The patient had concurrent SARS-CoV-2 infection. Despite medical and surgical antimicrobial treatment, stroke prevention, and venous thrombosis prevention, he presented with severe cerebrovascular complications. Venous thrombosis and stroke were observed, with an extension of intracranial vasculitis, and lead to death. As both F. necrophorum and SARS-CoV-2 enhance inflammation, coagulation, and activate endothelial cells, we discuss how this coinfection may have potentiated and aggravated the usual course of LS. The potentiation by SARS-CoV-2 of vascular and thrombotic effects of a bacterial infection may represent an underreported cerebrovascular injury mechanism in Covid-19 patients. These findings emphasize the variety of mechanisms underlying stroke in this disease. Moreover, in the setting of SARS-CoV-2 pandemic, we discuss in what extent sanitary measures, namely, lockdown and fear to attend medical facilities, may have delayed diagnosis and influenced outcomes. This case also emphasizes the role of clinical assessment and the limits of telemedicine for acute neurological condition diagnosis.

Skin manifestations of COVID-19 in children: Part 2

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults, as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discussed one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions. In this part of the review, we describe other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

COVID-19 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review of critically unwell children and the association with underlying comorbidities

Data show that children are less severely affected with SARS-Covid-19 than adults; however, there have been a small proportion of children who have been critically unwell. In this systematic review, we aimed to identify and describe which underlying comorbidities may be associated with severe SARS-CoV-2 disease and death. The study protocol was in keeping with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A total of 1726 articles were identified of which 28 studies fulfilled the inclusion criteria. The 28 studies included 5686 participants with confirmed SARS-CoV-2 infection ranging from mild to severe disease. We focused on the 108 patients who suffered from severe/critical illness requiring ventilation, which included 17 deaths. Of the 108 children who were ventilated, the medical history was available for 48 patients. Thirty-six of the 48 patients (75%) had documented comorbidities of which 11/48 (23%) had pre-existing cardiac disease. Of the 17 patients who died, the past medical history was reported in 12 cases. Of those, 8/12 (75%) had comorbidities.Conclusion: Whilst only a small number of children suffer from COVID-19 disease compared to adults, children with comorbidities, particularly pre-existing cardiac conditions, represent a large proportion of those that became critically unwell. What is Known: • Children are less severely affected by SARS-CoV-2 than adults. • There are reports of children becoming critically unwell with SARS-CoV-2 and requiring intensive care. What is New: • The majority of children who required ventilation for SARS-CoV-2 infection had underlying comorbidities. • The commonest category of comorbidity in these patients was underlying cardiac disease.

Factors Associated With Severe SARS-CoV-2 Infection

BACKGROUND

Initial reports on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in children suggested that very young age and comorbidities may increase risk of severe evolution, but these findings remained to be confirmed. We aimed to analyze the clinical spectrum of hospitalized pediatric SARS-CoV-2 infection and predictors of severe disease evolution.

METHODS

We conducted a French national prospective surveillance of children hospitalized with SARS-CoV-2 infection. We included all children with confirmed SARS-CoV-2 infection in 60 hospitals during February 15 to June 1, 2020. The main outcome was the proportion of children with severe disease, defined by hemodynamic or ventilatory (invasive or not) support requirement.

RESULTS

We included 397 hospitalized children with SARS-CoV-2 infection. We identified several clinical patterns, ranging from paucisymptomatic children, admitted for surveillance, to lower respiratory tract infection or multisystem inflammatory syndrome in children. Children <90 days old accounted for 37% of cases (145 of 397), but only 4 (3%) had severe disease. Excluding children with multisystem inflammatory syndrome in children (n = 29) and hospitalized for a diagnosis not related to SARS-CoV-2 (n = 62), 23 of 306 (11%) children had severe disease, including 6 deaths. Factors independently associated with severity were age ≥10 years (odds ratio [OR] = 3.4, 95% confidence interval: 1.1-10.3), hypoxemia (OR = 8.9 [2.6-29.7]), C-reactive protein level ≥80 mg/L (OR = 6.6 [1.4-27.5]).

CONCLUSIONS

In contrast with preliminary reports, young age was not an independent factor associated with severe SARS-CoV-2 infection, and children <90 days old were at the lowest risk of severe disease evolution. This may help physicians to better identify risk of severe disease progression in children.

Neurologic Care of COVID-19 in Children

Most children with SARS-CoV-2 infection have relatively mild clinical symptoms without fever or pneumonia, although severe cases with multiple-organ failure have been reported. Neurological symptoms, which have been mainly reported in adults, are very rare in children. This article will review 2 different aspects of neurological involvement related to this infection in children. In the first part, we will review the neurological abnormalities reported in children caused by this viral infection. Adults frequently report muscle pain, headache, anosmia, dysgeusia, and occasionally more severe central or peripheral nervous system damage. Neurological involvement seems infrequent in children, although some cases have been reported. In the second part, we will discuss the COVID-19 pandemic impact on the healthcare system of some countries, causing collateral damage to general pediatric care and in particular to those children affected with chronic diseases, mainly neurological conditions, including autism, intellectual disability, attention deficit and hyperactivity disorder (ADHD), neuromuscular disorders, cerebral palsy, and epilepsy, and patients needing neurosurgical procedures.

Reopening schools in the context of increasing COVID-19 community transmission: The French experience

BACKGROUND AND OBJECTIVES

The role of schools in the spread of SARS-CoV-2 infections in the community is still controversial. The objective of our study was to describe the epidemiology of SARS-CoV-2 infections in different pediatric age groups during the first 2 months of the fall back-to-school period, in the context of increasing viral transmission in France.

METHODS

Weekly epidemiological data provided by Santé Publique France and the Ministry of National Education were analyzed according to the age groups defined by the different school levels. Weeks (W) 34-42 were considered for analysis.

RESULTS

The PCR positivity rate and incidence rate increased in all age groups during the study period, in an age-dependent manner. At W42, with adults being considered as reference, the risk ratio for a positive PCR test was 0.46 [95% CI: 0.44-0.49] and 0.69 [0.68-0.70] for children aged 0-5 years and 6-17 years, respectively. Similarly, the incidence rate ratio was 0.09 [0.08-0.09], 0.31 [0.30-0.32], 0.64 [0.63-0.66], and 1.07 [1.05-1.10] for children aged 0-5 years, 6-10 years, 11-14 years, and 15-17 years, respectively. Children and adolescents accounted for 1.9% of the newly hospitalized patients between W34 and W42, and for 1.3% of new intensive care admissions. No death was observed. Among infected children and adolescents, the percentage of asymptomatic individuals was 57% at W34 and 48% at W42. The number of schools closed remained low, less than 1% throughout the study period. The number of confirmed cases among school staff was consistent with the data measured in the general population.

CONCLUSION

In the context of increasing viral transmission in the population, the spread among children and adolescents remained lower than that observed among adults, despite keeping schools open. However, the impact was age-dependent, with data in high schools close to those observed in adults.

Risk Factors for Severity in Children with Coronavirus Disease 2019: A Comprehensive Literature Review

The coronavirus disease 2019 (COVID-19) pandemic has affected hundreds of thousands of people. The authors performed a comprehensive literature review to identify the underlying mechanisms and risk factors for severe COVID-19 in children. Children have accounted for 1.7% to 2% of the diagnosed cases of COVID-19. They often have milder disease than adults, and child deaths have been rare. The documented risk factors for severe disease in children are young age and underlying comorbidities. It is unclear whether male gender and certain laboratory and imaging findings are also risk factors. Reports on other potential factors have not been published.

Update on SARS-CoV-2 infection in children

Despite the worldwide spread of SARS-CoV-2 infection (COVID-19), knowledge of the different clinical presentations, ways of transmission, severity and prognosis in children and adolescents is limited. An increasing number of reports describe some of these characteristics in this age range. A non-systematic review was undertaken using MEDLINE (PubMed), LILACS (VHL), Scopus, Web of Science, Cochrane and CAPES Portal databases from 1 January until 30 September 2020 [103] with the search terms SARS-CoV-2, COVID-19, child, children, youth, adolescent and newborn to identify the more recent clinical aspects of SARS-CoV-2 infection in children. In general, SARS-CoV-2 infection in children tends to be asymptomatic or to have mild or moderate signs, and most young ones are infected by family members. Recent reports offer new insights into the disease. Current evidence on SARS-CoV-2 infection in children and adolescents is presented, especially concerning the clinical presentation, imaging and uncommon severe forms of the disease, particularly the COVID-19-associated multisystem inflammatory syndrome. The impact of COVID-19 infection in the perinatal period is described in detail. Knowledge of the various clinical presentations of SARS-CoV-2 in children and adolescents allows the paediatrician to diagnose earlier, monitor warnings signs, implement treatment and, especially, establish preventive measures.Abbreviations : ACE-2, angiotensin-converting enzyme 2; ARDS, acute respiratory distress syndrome; ARF, acute rheumatic fever; CAA, coronary artery aneurysms; CK-MB, creatine kinase-MB; COVID-19, coronavirus disease-2019; HLA, specific human leucocyte antigen; IPC, infection prevention and control; IVIG, intravenous immunoglobulin; KD, Kawasaki disease; MIS-C, COVID-19-associated multisystem inflammatory syndrome; RNA, ribonucleic acid; RT-PCR, reserve transcription-polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus-2; TCT, thoracic computed tomography; TSS, toxic shock syndrome; WHO, World Health Organization.

Neurological issues in children with COVID-19

Coronavirus disease 2019 (COVID-19) usually leads to a mild infectious disease course in children, but serious complications may occur in conjunction with both acute infection and associated phenomena such as the multisystem inflammatory syndrome in children (MIS-C). Neurological symptoms, which have been predominantly reported in adults, range from mild headache to seizure, peripheral neuropathy, stroke, demyelinating disorders, and encephalopathy. Similar to respiratory and cardiac manifestations of COVID-19, neurological complications present differently based on age and underlying comorbidities. This review provides a concise overview of the neurological conditions seen in the context of COVID-19, as well as potential mechanisms and long-term implications of COVID-19 in the pediatric population from literature reviews and primary data collected at NewYork-Presbyterian Morgan Stanley Children's Hospital.

COVID-19 infection in children: A systematic review and meta-analysis of clinical features and laboratory findings

OBJECTIVE

We aimed to provide a meta-analysis of previously published papers on the COVID-19-related clinical features and laboratory findings in children.

METHOD

This meta-analysis was conducted by using Medline/PubMed, Scopus, Web of Sciences and Google Scholar. Finally, 32 articles were selected for full-text assessment.

RESULTS

The most frequent symptoms were fever, cough, vomiting, diarrhea, sore throat, and dyspnea. Regarding the combined results of the meta-analysis, fever (46%, 95% CI 40-53%), cough (37%, 95% CI 29-46%), diarrhea (19%, 95% CI 9-28%), and pharyngalgia (13%, 95% CI 5-20%) were the most widely reported symptom. Besides, positive RT-PCR test results (43%, 95% CI 33-53%), low oxygen saturation (38%, 95% CI 25-51%), and elevated D-dimer levels (36%, 95% CI 16-56%) were the most common laboratory findings.

CONCLUSION

This review found that clinical presentations were milder, the prognosis was better, and the mortality rate was lower in children with COVID-19 compared with adult patients; however, children are potential carriers, like adults, and can transmit the infection among the population. Therefore, early identification and intervention in pediatric patients with COVID-19 are essential in order to control the pandemic. Moreover, gastrointestinal symptoms were more common symptoms among children.

Initial Guidance on Use of Monoclonal Antibody Therapy for Treatment of Coronavirus Disease 2019 in Children and Adolescents

BACKGROUND

In November 2020, the US Food and Drug Administration (FDA) provided Emergency Use Authorizations (EUA) for 2 novel virus-neutralizing monoclonal antibody therapies, bamlanivimab and REGN-COV2 (casirivimab plus imdevimab), for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adolescents and adults in specified high-risk groups. This has challenged clinicians to determine the best approach to use of these products.

METHODS

A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacy, pediatric intensive care medicine, and pediatric hematology from 29 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a guidance statement was developed and refined based on review of the best available evidence and expert opinion.

RESULTS

The course of COVID-19 in children and adolescents is typically mild and there is no high-quality evidence supporting any high-risk groups. There is no evidence for safety and efficacy of monoclonal antibody therapy for treatment of COVID-19 in children or adolescents, limited evidence of modest benefit in adults, and evidence for potential harm associated with infusion reactions or anaphylaxis.

CONCLUSIONS

Based on evidence available as of December 20, 2020, the panel suggests against routine administration of monoclonal antibody therapy (bamlanivimab, or casirivimab and imdevimab), for treatment of COVID-19 in children or adolescents, including those designated by the FDA as at high risk of progression to hospitalization or severe disease. Clinicians and health systems choosing to use these agents on an individualized basis should consider risk factors supported by pediatric-specific evidence and ensure the implementation of a system for safe and timely administration that does not exacerbate existing healthcare disparities.

Pediatric and neonatal extracorporeal life support: current state and continuing evolution

The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.

Clinical-epidemiological profile of children and adolescents with COVID-19 in Ceará

Abstract Objectives: to describe the clinical-epidemiological profile of children and adolescents notified by COVID-19 in Ceará. Methods: descriptive epidemiological study from open data repositories of the State Government of Ceará, about cases of OVID-19 in children and adolescents, from 03/15/2020 to 07/31/2020. For data analysis the tests χ2 Pearson, Fisher's exact and Poisson's regression with robust variance were used. Results: 48,002 cases of children and adolescents suspected of COVID-19 were reported, of which 18,180 (8.9%) were confirmed. The median of confirmed cases was 12 years old, 10.5% were newborns/lactants, 10.7% were pre-school children, 21.2% were school children and 57.7% were adolescents. They evolved to death 0.3% of the cases, of which 15% had comorbidities. They needed hospitalization 1.8% of the cases. The highest probability of hospitalization was found in newborns/lactants, male and with comorbidities. Conclusions: most of the confirmed cases occurred in adolescents, however, the evolution of the disease was more severe and with greater need for hospitalization in the age group of newborns/lactants, being the male gender and the presence of comorbidities additional factors for the need for hospitalization.

Transmission of SARS-CoV-2 through breast milk and breastfeeding: a living systematic review

The pandemic of coronavirus disease 2019 (COVID-19) is caused by infection with a novel coronavirus strain, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). At present, there is limited information on potential transmission of the infection from mother to child, particularly through breast milk and breastfeeding. Here, we provide a living systematic review to capture information that might necessitate changes in the guidance on breast milk and breastfeeding given the uncertainty in this area. Our search retrieved 19,414 total records; 605 were considered for full-text eligibility and no ongoing trials were identified. Our review includes 340 records, 37 with breast milk samples and 303 without. The 37 articles with analyzed breast milk samples reported on 77 mothers who were breastfeeding their children; among them, 19 of 77 children were confirmed COVID-19 cases based on RT-PCR assays, including 14 neonates and five older infants. Nine of the 68 analyzed breast milk samples from mothers with COVID-19 were positive for SARS-CoV-2 RNA; of the exposed infants, four were positive and two were negative for COVID-19. Currently, there is no evidence of SARS-CoV-2 transmission through breast milk. Studies are needed with longer follow-up periods that collect data on infant feeding practices and on viral presence in breast milk.

Neumonía por COVID-19 en niños: De su etiología a su manejo

El COVID-19 es menos serio en niños que en adultos. Sin embargo, las afecciones respiratorias dominan el cuadro clínico de pacientes hospitalizados por COVID-19, aun en niños. En algunas series de casos, el deterioro del estado clínico, donde la disnea, la cianosis y el inicio del síndrome de dificultad respiratoria aguda (SDRA) emergieron ∼8–10 días después del inicio de la infección por SARS-CoV-2, pudo progresar rápidamente hasta la falla multiorgánica y la muerte. Esta revisión tiene como objetivo evaluar las características de la neumonía por COVID-19 en poblaciones pediátricas, comenzando con su etiología y sus mecanismos patológicos, para cerrar con su manejo clínico.

Hemoglobinopathy and pediatrics in the time of COVID-19

INTRODUCTION

It is important to know if patients with hemoglobinopathy could be more susceptible to COVID-19.

OBJECTIVE

Analyze SARS-CoV-2 infection in pediatric patients with hemoglobinopathy.

METHODS

Using the online platforms LILACS, PUBMED and EMBASE, on 17- JUL-2020 a search was made for the terms COVID-19 and SARS-CoV-2 associated with "sickle cell", "thalassemia" and "hemoglobinopathy".

RESULTS

There were 623 pediatric and adult patients with sickle cell disease (SCD) or beta thalassemia (BT) and COVID-19. Total mortality rate was 6.42%. No pediatric patient with BT has been described. So, our analysis focused on children and adolescents with SCD: there were 121 pediatric patients, one adolescent died, prophylactic anticoagulation was prescribed to six patients, 11.76% needed intensive care unit, blood transfusion was prescribed in 29.70%. Vaso-occlusive crisis (VOC) and acute chest syndrome (ACS) were the main clinical manifestations in SCD.

DISCUSSION

Pediatric patients with SCD and COVID-19 have a low mortality rate when compared to adults, although is higher than the global pediatric population with COVID-19 (0-0.67%). The comorbidities associated with age and the long-term complications inherent to hemoglobinopathies may contribute to the increased mortality outside the pediatric age group. In SCD the clinical manifestations, both in children and adults, are VOC and ACS, and there was increase in blood requirement. Pediatric SCD patients with COVID-19 need more intensive care unit than the global pediatric population (3.30%).

CONCLUSION

Despite pediatric population with SCD needs more intensive care, the outcome after infection by COVID-19 is favorable.

Heterogeneous Recommendations for School Attendance in Children With Chronic Kidney Diseases During the COVID-19 Pandemic in Europe

Introduction: After worldwide closures due to the COVID-19 pandemic, schools have reopened in most European countries in late 2020. Consequently, for children with chronic diseases the risks of COVID-19 have to be weighed against the long-time risks of missing school. Methods: To evaluate the impact of chronic diseases on school attendance for children in Europe during the COVID-19 pandemic we conducted a survey among members of the European Society for Pediatric Nephrology (ESPN) between September and November 2020. We asked for current forms of schooling, the existence of national guidelines, parental concerns, and the pediatric nephrologists recommendations for school attendance for specific virtual patients with chronic kidney disease (CKD). Results: Recommendations varied widely among pediatric nephrologists. A minority stated that specific recommendations for COVID-19 risk in children with kidney diseases existed in their country from local health authorities (9 of 29 countries; 31%) and/or national pediatric nephrology societies (9 of 29 countries; 31%). Over 90% of physicians have experienced parents keeping their children out of school against medical advice of their health providers and about 50% have experienced their patients being refused by school authorities. Consequently, 25% of all pediatric nephrologists estimated that more than 10% of their patients will not attend school regularly. Conclusion: COVID-19 causes educational deficits in the already vulnerable population of children with CKD. As the evidence for the course of COVID-19 in children with chronic diseases grows, rapidly adapted recommendations from pediatric societies could help reduce uncertainty among doctors, patients, and parents.

Private Tour Guide to Pediatric Coronavirus Disease of 2019 and Multisystem Inflammatory Syndrome in Children in 10 Minutes: What Thoracic Radiologists Need to Know

Filtering through the plethora of radiologic studies generated in response to the coronavirus disease of 2019 (COVID-19) pandemic can be time consuming and impractical for practicing thoracic radiologists with busy clinical schedules. To further complicate matters, several of the imaging findings in the pediatric patients differ from the adult population. This article is designed to highlight clinically useful information regarding the imaging manifestations of pediatric COVID-19 pneumonia, including findings more unique to pediatric patients, and multisystem inflammatory syndrome in children.

Severe Brain Damage in a Moderate Preterm Infant as Complication of Post-COVID-19 Response during Pregnancy

Current evidence from the COVID-19 pandemic suggests that neonatal SARS-coronavirus-2 infections usually have a mild course. Data on how maternal infection during pregnancy affects fetal development are scarce. We present the unique case of a moderate preterm infant with intracranial bleeding and periventricular leukomalacia as a potential consequence of post-COVID-19 hyperinflammation during pregnancy.

COVID-19 y enfermedad pulmonar pediátrica: Experiencia en un centro de atención terciaria en Sudáfrica

La pandemia de COVID-19 resultó en una rápida diseminación global, con profundos impactos en los sistemas de salud. Aunque los datos pediátricos muestran de manera consistente un cuadro clínico más leve, se ha identificado que la enfermedad pulmonar crónica es un factor de riesgo para la hospitalización y para desarrollar una enfermedad grave. En África, continente formado predominantemente por países con ingresos bajos o medios (LMIC), la elevada prevalencia de VIH, tuberculosis, desnutrición y hacinamiento aumenta aún más los riesgos a la salud. En este trabajo se revisa la literatura sobre COVID-19 y enfermedad pulmonar crónica en niños, y relata nuestra experiencia en un centro de atención pulmonar pediátrico en Ciudad del Cabo, Sudáfrica. Los datos epidemiológicos en Sudáfrica confirman una baja prevalencia de la enfermedad grave, donde los pacientes < 18 años comprenden 8% de todos los casos diagnosticados de COVID-19 y 3% de todas las admisiones por esa causa. Se encontró una reducción en la admisión hospitalaria por otras infecciones del tracto respiratorio inferior. Aunque el servicio de pulmonología atiende niños con una amplia variedad de condiciones respiratorias crónicas, incluyendo bronquiectasias, fibrosis quística, asma, enfermedad pulmonar intersticial y pacientes con traqueostomías, no se observó un incremento significativo en las admisiones por COVID-19, y en quienes desarrollaron COVID-19, el curso de la enfermedad no fue grave. La evidencia actual sugiere que la preexistencia de una enfermedad respiratoria en niños no parece ser un factor de riesgo significativo para el COVID-19 grave. Aún se requieren datos longitudinales para evaluar el riesgo en niños con inmunosupresión y enfermedades pulmonares intersticiales. Los impactos indirectos de la respuesta a la pandemia en la salud respiratoria de los niños son notables, y es muy probable que aún deban comprenderse y cuantificarse. Garantizar el acceso de los niños a servicios preventivos y de cuidado completos durante este tiempo es prioritario.

COVID-19 Pneumonia in Children: From Etiology to Management

COVID-19 is less serious in children than in adults. However, respiratory management dominates the clinical picture of hospitalized COVID-19 even in children. In some case series, deterioration of the clinical picture wherein dyspnea, cyanosis, and the onset of acute respiratory distress syndrome (ARDS) emerged ~8-10 days after the onset of SARS-CoV-2 infection, which could rapidly progress to multiple organ failure and death. This review aimed to evaluate the characteristics of COVID-19 pneumonia in pediatric populations, beginning from its etiology and pathological mechanisms and closing with its clinical management.

Coronavirus global pandemic: An overview of current findings among pediatric patients

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic has been emerged as a cardinal public health problem. Children have their own specific clinical features; notably, they seem to be escaping the severe respiratory adverse effects. The international scientific community is rapidly carrying out studies, driving to the need to reassess knowledge of the disease and therapeutic strategies.

AIM

To assess the characteristics of COVID-19 infected children worldwide of all ages, from neonates to children and adolescents, and how they differ from their adult counterparts.

SEARCH STRATEGY

An electronic search in PubMed was conducted, using combinations of the following keywords: coronavirus, SARS-CoV-2, COVID-19, children. The search included all types of articles written in English between January 1, 2019 until August 15, 2020.

RESULTS

The search identified 266 relevant articles. Children were mainly within family clusters of cases and have relatively milder clinical presentation compared with adults; children were reported to have better outcomes with a significantly lower mortality rate. Cough and fever were the most common symptoms while pneumonia was the cardinal respiratory manifestation of infected children. Laboratory results and thoracic imaging give varying results.

CONCLUSIONS

Children were mainly family cluster cases and usually presented with a mild infection, although cases presented with the multisystem inflammatory syndrome are becoming more apparent. Studies determining why the manifestations of SARS-CoV-2 infection are so variable may help to gain a better understanding of the disease and accelerate the development of vaccines and therapies.

Severe COVID-19 Infection and Pediatric Comorbidities: A Systematic Review and Meta-Analysis

OBJECTIVE

There is limited information on the severity of COVID-19 infection in children with comorbidities. We investigated the effects of pediatric comorbidities on COVID-19 severity by means of a systematic review and meta-analysis of published literature.

METHODS

PubMed, Embase, and Medline databases were searched for publications on pediatric COVID-19 infections published January 1^st to October 5^th, 2020. Articles describing at least one child with and without comorbidities, COVID-19 infection, and reported outcomes were included.

RESULTS

42 studies containing 275,661 children without comorbidities and 9,353 children with comorbidities were included. Severe COVID-19 was present in 5.1% of children with comorbidities, and in 0.2% without comorbidities. Random-effects analysis revealed a higher risk of severe COVID-19 among children with comorbidities than for healthy children; relative risk ratio 1.79 (95% CI 1.27 - 2.51; I² = 94%). Children with underlying conditions also had a higher risk of COVID-19-associated mortality; relative risk ratio 2.81 (95% CI 1.31 - 6.02; I² = 82%). Children with obesity had a relative risk ratio of 2.87 (95% CI 1.16 - 7.07; I² = 36%).

CONCLUSIONS

Children with comorbidities have a higher risk of severe COVID-19 and associated mortality than children without underlying disease. Additional studies are required to further evaluate this relationship.

Fulminant hepatic failure: A rare and devastating manifestation of Coronavirus disease 2019 in an 11-year-old boy

Although several typical manifestation of novel coronavirus disease 2019 (COVID-19) including respiratory symptoms, weakness, fever, and fatigue have been reported, some rare and novel manifestations have also been observed, particularly in children. We report a pediatric case of fulminant hepatic failure associated with COVID-19. Although the patient was treated for acute fulminant hepatic failure in the context of COVID-19, he died following the progression of the disease to stage 4 hepatic failure with encephalopathy and brain death.

COVID-19 and schools. Guidelines of the French Pediatric Society

The educational and social benefits provided by school far outweigh the risks of a possible COVID-19 contamination of children in school environments or in daycare centers. Following summer break, the back-to-school period in France is taking place in the context of an increasing viral spread and requires strict adherence to health measures to limit the risk of outbreaks in communities. Based on a critical update of the role of children in the transmission of the infection, and of children's susceptibility to infection, the French Pediatric Society published practical guidelines for school re-entry and the management of COVID-19 infections in schools.

Convalescent plasma to aid in recovery of COVID-19 pneumonia in a child with acute lymphoblastic leukemia

The natural history of COVID-19 infection in children is still evolving as the pandemic unfolds. Few cases of severe and often fatal COVID-19 have been reported although the infection is mild in the large majority. Children with cancers are recognised as a high risk group for all infections. Since there aren’t any definite treatment guidelines established in children with severe COVID, treatment is guided by adult recommendations which too are often not evidence based. We report the case of a 4-year-old girl with severe COVID-19 associated pneumonia who presented to us as febrile neutropenia. The use of convalescent plasma along with steroids and IVIG showed dramatic results in this child and she recovered without the need for any specific treatment. This is highlighted as one of the earliest cases that is reporting the use of convalescent plasma in a child; the first ever in a child with underlying malignancy.

Review of Current Vaccine Development Strategies to Prevent Coronavirus Disease 2019 (COVID-19)

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) outbreak that started in Wuhan, China, in 2019 resulted in a pandemic not seen for a century, and there is an urgent need to develop safe and efficacious vaccines. The scientific community has made tremendous efforts to understand the disease, and unparalleled efforts are ongoing to develop vaccines and treatments. Toxicologists and pathologists are involved in these efforts to test the efficacy and safety of vaccine candidates. Presently, there are several SARS-CoV-2 vaccines in clinical trials, and the pace of vaccine development has been highly accelerated to meet the urgent need. By 2021, efficacy and safety data from clinical trials are expected, and potentially a vaccine will be available for those most at risk. This review focuses on the ongoing SARS-CoV-2 vaccine development efforts with emphasis on the nonclinical safety assessment and discusses emerging preliminary data from nonclinical and clinical studies. It also provides a brief overview on vaccines for other coronaviruses, since experience gained from these can be useful in the development of SARS-CoV-2 vaccines. This review will also explain why, despite this unprecedented pace of vaccine development, rigorous standards are in place to ensure nonclinical and clinical safety and efficacy. [Box: see text].

Pediatric patients with COVID-19 admitted to intensive care units in Brazil: a prospective multicenter study

OBJECTIVE

To describe the clinical characteristics of children and adolescents admitted to intensive care with confirmed COVID-19.

METHOD

Prospective, multicenter, observational study, in 19 pediatric intensive care units. Patients aged 1 month to 19 years admitted consecutively (March-May 2020) were included. Demographic, clinical-epidemiological features, treatment, and outcomes were collected. Subgroups were compared according to comorbidities, age < 1 year, and need for invasive mechanical ventilation. A multivariable logistic regression model was used for predictors of severity.

RESULTS

Seventy-nine patients were included (ten with multisystemic inflammatory syndrome). Median age 4 years; 54% male (multisystemic inflammatory syndrome, 80%); 41% had comorbidities (multisystemic inflammatory syndrome, 20%). Fever (76%), cough (51%), and tachypnea (50%) were common in both groups. Severe symptoms, gastrointestinal symptoms, and higher inflammatory markers were more frequent in multisystemic inflammatory syndrome. Interstitial lung infiltrates were common in both groups, but pleural effusion was more prevalent in the multisystemic inflammatory syndrome group (43% vs. 14%). Invasive mechanical ventilation was used in 18% (median 7.5 days); antibiotics, oseltamivir, and corticosteroids were used in 76%, 43%, and 23%, respectively, but not hydroxychloroquine. The median pediatric intensive care unit length-of-stay was five days; there were two deaths (3%) in the non- multisystemic inflammatory syndrome group. Patients with comorbidities were older and comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5; 95% CI, 1.43-21.12; p = 0.01).

CONCLUSIONS

In Brazilian pediatric intensive care units, COVID-19 had low mortality, age less than 1 year was not associated with a worse prognosis, and patients with multisystemic inflammatory syndrome had more severe symptoms, higher inflammatory biomarkers, and a greater predominance of males, but only comorbidities and chronic diseases were independent predictors of severity.

COVID‐19 and obesity in childhood and adolescence: a clinical review

Objetivo

Identificar fatores que contribuem para o aumento da suscetibilidade e gravidade da COVID‐19 em crianças e adolescentes obesos e suas consequências para a saúde.

Fontes de dados

Estudos publicados entre 2000 e 2020 nas bases de dados PubMed, Medline, Scopus, SciELO e Cochrane.

Síntese dos dados

A obesidade é uma comorbidade altamente prevalente em casos graves de COVID‐19 em crianças e adolescentes e o isolamento social pode levar ao aumento do acúmulo de gordura. Tecido adiposo excessivo, déficit de massa magra, resistência à insulina, dislipidemia, hipertensão, altos níveis de citocinas pró‐inflamatórias e baixa ingestão de nutrientes essenciais são fatores que comprometem o funcionamento dos órgãos e sistemas no indivíduo obeso. Esses fatores estão associados a danos nos sistemas imunológico, cardiovascular, respiratório e urinário, juntamente com a modificação da microbiota intestinal (disbiose). Na infecção por SARS‐CoV‐2, essas alterações orgânicas causadas pela obesidade podem aumentar a necessidade de assistência ventilatória, risco de tromboembolismo, taxa de filtração glomerular reduzida, alterações na resposta imune inata e adaptativa e perpetuação da resposta inflamatória crônica.

Conclusões

A necessidade de isolamento social pode ter o efeito de causar ou agravar a obesidade e suas comorbidades e pediatras precisam estar cientes desse problema. Diante de crianças com suspeita ou confirmação de COVID‐19, os profissionais de saúde devem 1) diagnosticar o excesso de peso; 2) aconselhar sobre cuidados de saúde em tempos de isolamento; 3) fazer a triagem de comorbidades, garantindo que o tratamento não seja interrompido; 4) medir os níveis de imunonutrientes; 5) orientar a família respeitando as especificidades da situação; e 6) encaminhamento a unidades qualificadas para cuidar de crianças e adolescentes obesos, quando necessário.

Pediatric patients with COVID‐19 admitted to intensive care units in Brazil: a prospective multicenter study

Objetivo

Descrever as características clínicas de crianças e adolescentes internados em unidade de terapia intensiva com COVID‐19 confirmada.

Método

Estudo prospectivo, multicêntrico, observacional, em 19 unidades de terapia intensiva pediátrica. Foram incluídos pacientes entre um mês e 19 anos, admitidos consecutivamente (março a maio de 2020). As características demográficas, clínico‐epidemiológicas, o tratamento e os resultados foram coletados. Os subgrupos foram comparados de acordo com as comorbidades, idade < 1 ano e necessidade de ventilação mecânica invasiva. Um modelo de regressão logística multivariável foi utilizado para preditores de gravidade.

Resultados

Setenta e nove pacientes foram incluídos (10 com síndrome inflamatória multi-ssistêmica). Mediana de idade, quatro anos; 54% eram do sexo masculino (síndrome inflamatória multissistêmica, 80%); 41% tinham comorbidades (síndrome inflamatória multissistêmica, 20%). Febre (76%), tosse (51%) e taquipneia (50%) foram comuns nos dois grupos. Sintomas graves egastrointestinais e marcadores inflamatórios mais elevados foram mais frequentes na presença de síndrome inflamatória multissistêmica. Infiltrados intersticiais pulmonares foram comuns em ambos os grupos, mas o derrame pleural foi mais prevalente no grupo com síndrome inflamatória multissistêmica (43% vs. 14%). A ventilac¸ão mecânica invasiva foi utilizada em 18% (mediana 7,5 dias); antibióticos, oseltamivir e corticosteroides foram utilizados em 76%, 43% e 23%, respectivamente, mas não a hidroxicloroquina. A mediana do tempo de permanência na unidade de terapia intensiva pediátrica foi de 5 dias; duas mortes ocorreram (3%) no grupo não- síndrome inflamatória multissistêmica. Os pacientes com comorbidades eram mais velhos, e as comorbidades foram independentemente associadas à necessidade de ventilac¸ão mecânica invasiva(OR 5,5; IC95%, 1,43-21,12; P 0,01).

Conclusões

Nas unidades de terapia intensiva pediátrica brasileiras, a COVID‐19 apresentou baixa mortalidade, a idade inferior a um ano não foi associada a um pior prognóstico, os pacientes com síndrome inflamatória multissistêmica apresentaram sintomas mais graves, biomarcadores inflamatórios mais elevados e uma grande predominância no sexo masculino, mas apenas a presença de comorbidades e doenças crônicas foi um preditor independente de gravidade.

COVID-19 and obesity in childhood and adolescence: a clinical review

OBJECTIVE

To identify factors that contribute to the increased susceptibility and severity of COVID-19 in obese children and adolescents, and its health consequences.

SOURCES

Studies published between 2000 and 2020 in the PubMed, MEDLINE, Scopus, SciELO, and Cochrane databases.

SUMMARY OF FINDINGS

Obesity is a highly prevalent comorbidity in severe cases of COVID-19 in children and adolescents; social isolation may lead to increase fat accumulation. Excessive adipose tissue, deficit in lean mass, insulin resistance, dyslipidemia, hypertension, high levels of proinflammatory cytokines, and low intake of essential nutrients are factors that compromise the functioning of organs and systems in obese individuals. These factors are associated with damage to immune, cardiovascular, respiratory, and urinary systems, along with modification of the intestinal microbiota (dysbiosis). In severe acute respiratory syndrome coronavirus 2 infection, these organic changes from obesity may increase the need for ventilatory assistance, risk of thromboembolism, reduced glomerular filtration rate, changes in the innate and adaptive immune response, and perpetuation of the chronic inflammatory response.

CONCLUSIONS

The need for social isolation can have the effect of causing or worsening obesity and its comorbidities, and pediatricians need to be aware of this issue. Facing children with suspected or confirmed COVID-19, health professionals should 1) diagnose excess weight; 2) advise on health care in times of isolation; 3) screen for comorbidities, ensuring that treatment is not interrupted; 4) measure levels of immunonutrients; 5) guide the family in understanding the specifics of the situation; and 6) refer to units qualified to care for obese children and adolescents when necessary.

A Suggested Role of Human Growth Hormone in Control of the COVID-19 Pandemic

Covid19 is a worldwide pandemic challenge that started in Wuhan, China and spread to almost all countries on the planet within a few months. The causative virus was found to be highly contagious and, until now, considerably difficult to contain. A look at the epidemiological distribution of the disease over the planet has raised a number of questions whose answers could help us understand the behavior of the virus and consequently leads us to possible means of limitation of its spread or even flattening of the curve of morbidity and mortality. After the third decade of life, there is a progressive decline of growth hormone (GH) secretion by approximately 15% for every decade of adult life. The data from highly affected countries suggest a more aggressive course in the elderly, a double-time affection of males more than females, and the vulnerability of some risk groups of patients. Our observation is that GH deficiency is a common factor in all vulnerable patient groups. We think that there is a need for studying the role of growth hormone in the unique epidemiological pattern of Covid-19 so that it might help in the early detection and management of the high-risk groups as appropriate.