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Philip RR, Sentilles C, Johnson JN, Merlocco A, Ramakrishnan K, Ryan KA, Boston U, Sathanandam S. Lessons from the Pandemic: Role of Percutaneous ECMO and Balloon Atrial Septostomy in Multi-System Inflammatory Syndrome in Children. J Clin Med 2024; 13:2168. [PMID: 38673441 PMCID: PMC11050248 DOI: 10.3390/jcm13082168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Multi-system inflammatory syndrome in children (MIS-C) in the setting of COVID-19 can be associated with severe cardiopulmonary dysfunction. This clinical deterioration may sometimes necessitate veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We describe an algorithmic approach including the role of balloon atrial septostomy in this cohort. This is the first reported series of percutaneous VA-ECMO in pediatric patients with MIS-C for better outcomes. The lessons from this approach can be replicated in other pediatric clinical conditions and adds to the armament of multiple pediatric specialties.
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Affiliation(s)
- Ranjit R. Philip
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Claire Sentilles
- Division of General Pediatrics, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA;
| | - Jason N. Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Anthony Merlocco
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Karthik Ramakrishnan
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, 901 Madison Ave. Memphis, TN 38163, USA
| | - Kaitlin A. Ryan
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Umar Boston
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, 901 Madison Ave. Memphis, TN 38163, USA
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
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2
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Lee S, Erdem G, Yasuhara J. Multisystem inflammatory syndrome in children associated with COVID-19: from pathophysiology to clinical management and outcomes. Minerva Pediatr (Torino) 2024; 76:268-280. [PMID: 37284807 DOI: 10.23736/s2724-5276.23.07205-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C), also known as pediatric inflammatory multisystem syndrome (PIMS), is a new postinfectious illness associated with COVID-19, affecting children after SARS-CoV-2 exposure. The hallmarks of this disorder are hyperinflammation and multisystem involvement, with gastrointestinal, cardiac, mucocutaneous, and hematologic disturbances seen most commonly. Cardiovascular involvement includes cardiogenic shock, ventricular dysfunction, coronary artery abnormalities, and myocarditis. Now entering the fourth year of the pandemic, clinicians have gained some familiarity with the clinical presentation, initial diagnosis, cardiac evaluation, and treatment of MIS-C. This has led to an updated definition from the Centers for Disease Control and Prevention in the USA driven by increased experience and clinical expertise. Furthermore, the available evidence established expert consensus treatment recommendations supporting a combination of immunoglobulin and steroids. However, the pathophysiology of the disorder and answers to what causes this remain under investigation. Fortunately, long-term outcomes continue to look promising, although continued follow-up is still needed. Recently, COVID-19 mRNA vaccination is reported to be associated with reduced risk of MIS-C, while further studies are warranted to understand the impact of COVID-19 vaccines on MIS-C. We review the findings and current literature on MIS-C, including pathophysiology, clinical features, evaluation, management, and medium- to long-term follow-up outcomes.
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Affiliation(s)
- Simon Lee
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Guliz Erdem
- Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jun Yasuhara
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA -
- Center for Cardiovascular Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Cardiology, Royal Children's Hospital, Parkville, Australia
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3
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Jacobson JC, Ryan ML, Vogel AM, Mehl SC, Acker SN, Prendergast C, Padilla BE, Lee J, Chao SD, Martin NR, Russell KW, Larsen K, Harting MT, Linden AF, Ignacio RC, Slater BJ, Juang D, Jensen AR, Melhado CG, Pelayo JC, Zhong A, Spencer BL, Gadepalli SK, Maamari M, Jimenez Valencia M, Qureshi FG, Pandya SR. Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections. ASAIO J 2024; 70:146-153. [PMID: 37816012 DOI: 10.1097/mat.0000000000002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.
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Affiliation(s)
- Jillian C Jacobson
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark L Ryan
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Division of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Connor Prendergast
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Justin Lee
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Stephanie D Chao
- Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Nolan R Martin
- Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Katie W Russell
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Kezlyn Larsen
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Allison F Linden
- Section of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Romeo C Ignacio
- Division of Pediatric Surgery/Department of Surgery, University of California School of Medicine, La Jolla, California
| | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Aaron R Jensen
- Department of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, California
| | - Caroline G Melhado
- Department of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, California
| | - Juan Carlos Pelayo
- Division of Pediatric Surgery and Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Allen Zhong
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Brianna L Spencer
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan
- Department of Pediatric Surgery, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, Ann Arbor, Michigan
| | - Mia Maamari
- Division of Critical Care Medicine, UT Southwestern Medical Center, Children's Medical Center, Dallas, Texas
| | - Maria Jimenez Valencia
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faisal G Qureshi
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samir R Pandya
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Khoury M, Harahsheh AS, Raghuveer G, Dahdah N, Lee S, Fabi M, Selamet Tierney ES, Portman MA, Choueiter NF, Elias M, Thacker D, Dallaire F, Orr WB, Harris TH, Norozi K, Truong DT, Khare M, Szmuszkovicz JR, Pagano JJ, Manlhiot C, Farid P, McCrindle BW. Obesity and Outcomes of Kawasaki Disease and COVID-19-Related Multisystem Inflammatory Syndrome in Children. JAMA Netw Open 2023; 6:e2346829. [PMID: 38064213 PMCID: PMC10709775 DOI: 10.1001/jamanetworkopen.2023.46829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Obesity may affect the clinical course of Kawasaki disease (KD) in children and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Objective To compare the prevalence of obesity and associations with clinical outcomes in patients with KD or MIS-C. Design, Setting, and Participants In this cohort study, analysis of International Kawasaki Disease Registry (IKDR) data on contemporaneous patients was conducted between January 1, 2020, and July 31, 2022 (42 sites, 8 countries). Patients with MIS-C (defined by Centers for Disease Control and Prevention criteria) and patients with KD (defined by American Heart Association criteria) were included. Patients with KD who had evidence of a recent COVID-19 infection or missing or unknown COVID-19 status were excluded. Main Outcomes and Measures Patient demographic characteristics, clinical features, disease course, and outcome variables were collected from the IKDR data set. Using body mass index (BMI)/weight z score percentile equivalents, patient weight was categorized as normal weight (BMI <85th percentile), overweight (BMI ≥85th to <95th percentile), and obese (BMI ≥95th percentile). The association between adiposity category and clinical features and outcomes was determined separately for KD and MIS-C patient groups. Results Of 1767 children, 338 with KD (median age, 2.5 [IQR, 1.2-5.0] years; 60.4% male) and 1429 with MIS-C (median age, 8.7 [IQR, 5.3-12.4] years; 61.4% male) were contemporaneously included in the study. For patients with MIS-C vs KD, the prevalence of overweight (17.1% vs 11.5%) and obesity (23.7% vs 11.5%) was significantly higher (P < .001), with significantly higher adiposity z scores, even after adjustment for age, sex, and race and ethnicity. For patients with KD, apart from intensive care unit admission rate, adiposity category was not associated with laboratory test features or outcomes. For patients with MIS-C, higher adiposity category was associated with worse laboratory test values and outcomes, including a greater likelihood of shock, intensive care unit admission and inotrope requirement, and increased inflammatory markers, creatinine levels, and alanine aminotransferase levels. Adiposity category was not associated with coronary artery abnormalities for either MIS-C or KD. Conclusions and Relevance In this international cohort study, obesity was more prevalent for patients with MIS-C vs KD, and associated with more severe presentation, laboratory test features, and outcomes. These findings suggest that obesity as a comorbid factor should be considered at the clinical presentation in children with MIS-C.
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Affiliation(s)
- Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ashraf S Harahsheh
- Children's National Hospital, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | | | - Nagib Dahdah
- Division of Pediatric Cardiology, CHU Ste-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Simon Lee
- The Heart Center at Nationwide Children's Hospital, Columbus, Ohio
| | - Marianna Fabi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | | | | | - Nadine F Choueiter
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Matthew Elias
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Frédéric Dallaire
- Department of Pediatrics, Universite de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - William B Orr
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Tyler H Harris
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kambiz Norozi
- Department of Pediatrics, Pediatric Cardiology, Western University, London, Ontario, Canada
| | | | - Manaswitha Khare
- University of California San Diego/Rady Children's Hospital San Diego
| | | | - Joseph J Pagano
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Cedric Manlhiot
- Blalock-Taussig-Thomas Congenital Heart Center at Johns Hopkins University, Baltimore, Maryland
| | - Pedrom Farid
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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5
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Zheng YR, Weng B, Zhang QL, Wang SB, Chen Q. Successful use of VA-ECMO in the treatment of an infant with SARS-CoV-2 associated ARDS: A case experience of China and literature review. Respir Med Case Rep 2023; 46:101948. [PMID: 38046460 PMCID: PMC10689932 DOI: 10.1016/j.rmcr.2023.101948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
- Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Bin Weng
- Department of Pediatric Intensive Care Unit, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shi-Biao Wang
- Department of Pediatric Intensive Care Unit, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Watanabe A, Kani R, Iwagami M, Takagi H, Yasuhara J, Kuno T. Assessment of Efficacy and Safety of mRNA COVID-19 Vaccines in Children Aged 5 to 11 Years: A Systematic Review and Meta-analysis. JAMA Pediatr 2023; 177:384-394. [PMID: 36689319 PMCID: PMC9871947 DOI: 10.1001/jamapediatrics.2022.6243] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/15/2022] [Indexed: 01/24/2023]
Abstract
Importance Evidence of the efficacy and safety of messenger RNA (mRNA) COVID-19 vaccines in children aged 5 to 11 years has been emerging. Collecting these data will inform clinicians, families, and policy makers. Objective To evaluate the efficacy and safety of mRNA COVID-19 vaccines in children aged 5 to 11 years in a systematic review and meta-analysis. Data Sources PubMed and Embase databases were searched on September 29, 2022, without language restrictions. Study Selection Randomized clinical trials and observational studies comparing vaccinated vs unvaccinated children aged 5 to 11 years and reporting efficacy or safety outcomes were included. Studies reporting safety outcomes in vaccinated children only (ie, no control group) were also included. Data Extraction and Synthesis Two investigators independently extracted relevant data from each study. Odds ratios (ORs) for efficacy and safety outcomes and incidences of adverse events (AEs) following vaccination were synthesized using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology reporting guidelines. Main Outcomes and Measures The primary outcome was SARS-CoV-2 infections with or without symptoms. The secondary outcomes included symptomatic SARS-CoV-2 infections, hospitalizations, and multisystem inflammatory syndrome in children. The incidences of each AE following vaccination were also evaluated. Results Two randomized clinical trials and 15 observational studies involving 10 935 541 vaccinated children (median or mean age range, 8.0-9.5 years) and 2 635 251 unvaccinated children (median or mean age range, 7.0-9.5 years) were included. Two-dose mRNA COVID-19 vaccination compared with no vaccination was associated with lower risks of SARS-CoV-2 infections with or without symptoms (OR, 0.47; 95% CI, 0.35-0.64), symptomatic SARS-CoV-2 infections (OR, 0.53; 95% CI, 0.41-0.70), hospitalizations (OR, 0.32; 95% CI, 0.15-0.68), and multisystem inflammatory syndrome in children (OR, 0.05; 95% CI, 0.02-0.10). Two randomized clinical trials and 5 observational studies investigated AEs among vaccinated children. Most vaccinated children experienced at least 1 local AE following the first injection (32 494 of 55 959 [86.3%]) and second injection (28 135 of 46 447 [86.3%]). Vaccination was associated with a higher risk of any AEs compared with placebo (OR, 1.92; 95% CI, 1.26-2.91). The incidence of AEs that prevented normal daily activities was 8.8% (95% CI, 5.4%-14.2%) and that of myocarditis was estimated to be 1.8 per million (95% CI, 0.000%-0.001%) following the second injection. Conclusions and Relevance In this systematic review and meta-analysis, COVID-19 mRNA vaccines among children aged 5 to 11 years were associated with measures of efficacy in preventing SARS-CoV-2 infection and severe COVID-19-related illnesses. While most children developed local AEs, severe AEs were rare, and most of AEs resolved within several days. These data provide evidence for future recommendations.
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Affiliation(s)
- Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Ryoma Kani
- School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Masao Iwagami
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Jun Yasuhara
- Center for Cardiovascular Research, The Abigail Wexner Research Institute and The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
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