Characteristics of Hospitalized Children Positive for SARS-CoV-2: Experience of a Large Center

COVID-19 in Children With Severe Lung Disease-A Tertiary Center Cohort Study in Denmark

BACKGROUND

Severe lung disease such as chronic pulmonary disease (CPD), severe asthma and cystic fibrosis (CF) in children is associated with increased risk of severe COVID-19. Information regarding SARS-CoV-2 infection, disease severity and outcome of COVID-19 is limited in this pediatric population.

OBJECTIVES

We captured the number of SARS-CoV-2 infected children and evaluated COVID-19 disease severity in non-immunized children with CPD, asthma, and CF in a cohort at a Danish tertiary center.

METHODS

The number of children with PCR-verified SARS-CoV-2 infection in the cohort and in the age-related background population was identified through the Danish Microbiology Database. Clinical data were retrieved from the electronic medical health records and from the Danish Health Authority.

RESULTS

In a cohort of 664 children with severe lung disease 594 were either PCR-tested or had an antibody test for SARS-CoV-2 infection due to symptoms or exposure and 18 (3%) had verified SARS-CoV-2 infection. The total number of verified SARS-CoV-2 infection was at that time 34.575(4.342%) thus, not significantly different from the reference population (p = 0.152). The symptoms ranged from asymptomatic to mild symptoms, and none of the children with severe lung disease required hospitalization due to COVID-19. None of the children were treated with antiviral treatment during the acute infection.

CONCLUSION

Of the 664 children in the Danish cohort with severe lung disease, none were hospitalized with COVID-19. Our findings imply that this particular group of patients do not experience increased risk of severe COVID-19.

Refining the hospitalization rate: A mixed methods approach to differentiate primary COVID-19 from incidental cases

Purpose

Until now, the Hospitalization Rate (HR) served as an indicator (among others) for the COVID-19 associated healthcare burden. To ensure that the HR accomplishes its full potential, hospitalizations caused by COVID-19 (primary cases) and hospitalizations of patients with incidental positive SARS-CoV-2 test results (incidental cases) must be differentiated. The aim of this study was to synthesize the existing evidence on differentiation criteria between hospitalizations of primary cases and incidental cases.

Methods

An online survey of the members of the German Network University Medicine (NUM) was conducted. Additionally, senior clinicians with expertise in COVID-19 care were invited for qualitative, semi-structured interviews. Furthermore, a rapid literature review was undertaken on publications between 03/2020 and 12/2022.

Results

In the online survey (n=30, response rate 56%), pneumonia and acute upper respiratory tract infections were the most indicative diagnoses for a primary case. In contrast, malignant neoplasms and acute myocardial infarctions were most likely to be associated with incidental cases. According to the experts (n=6), the diagnosis, ward, and type of admission (emergency or elective), low oxygen saturation, need for supplemental oxygen, and initiation of COVID-19 therapy point to a primary case. The literature review found that respiratory syndromes and symptoms, oxygen support, and elevated levels of inflammatory markers were associated with primary cases.

Conclusion

There are parameters for the differentiation of primary from incidental cases to improve the objective of the HR. Ultimately, an updated HR has the potential to serve as a more accurate indicator of the COVID-19 associated healthcare burden.

Classification of SARS-CoV-2 Pediatric Hospitalizations: Delta vs Omicron Variant

OBJECTIVES

To classify COVID-19 pediatric hospitalizations based on reason for admission ("for COVID" or "with COVID") and to compare disease severity and age between the delta and omicron variant predominant time frames.

METHODS

This was a retrospective study in patients aged ≤18 years who were hospitalized at a large, tertiary care pediatric hospital for COVID-19 from July 2021 to February 2022. Disease severity was determined based on length of stay, PICU admission, and Remdesivir receipt. A χ2 analysis and a Cochran-Mantel-Haenszel test were used to analyze relationships between presumed variant type with admission reason, disease severity, and age.

RESULTS

There were 492 patients included with more admissions during the omicron variant predominant time frame (n = 307). More patients were admitted "for COVID" during the delta variant predominant time frame compared with the omicron variant predominant time frame (P < .001) with interrater reliability testing indicating substantial agreement between reviewers. PICU admissions (P < .001), receipt of remdesivir (P < .001), and length of stay (P < .001) were greater during the delta variant predominant time frame. Hospitalizations "for COVID" were more common in patients aged <5 years during both the delta (odds ratio, 2.6; 95% confidence interval, 1.2-5.7) and omicron (odds ratio, 5.7; 95% confidence interval, 3.4-9.4) predominant time frames compared with older patients.

CONCLUSIONS

There was a higher proportion of symptomatic COVID-19 hospitalizations with higher disease severity during the delta variant predominance, indicating greater disease severity during earlier periods of the pandemic despite lower hospitalization rates.

SARS-CoV-2 infection in children: A 24 months experience with focus on risk factors in a pediatric tertiary care hospital in Milan, Italy

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children is characterized by a wide variety of expressions ranging from asymptomatic to, rarely, critical illness. The basis of this variability is not yet fully understood. The aim of this study was to identify clinical and genetic risk factors predisposing to disease susceptibility and progression in children.

METHODS

We enrolled 181 consecutive children aged less than 18 years hospitalized with or for SARS-CoV-2 infection during a period of 24 months. Demographic, clinical, laboratory, and microbiological data were collected. The development of coronavirus disease 2019 (COVID-19)-related complications and their specific therapies were assessed. In a subset of 79 children, a genetic analysis was carried out to evaluate the role of common COVID-19 genetic risk factors (chromosome 3 cluster; ABO-blood group system; FUT2, IFNAR2, OAS1/2/3, and DPP9 loci).

RESULTS

The mean age of hospitalized children was 5.7 years, 30.9% of them being under 1 year of age. The majority of children (63%) were hospitalized for reasons different than COVID-19 and incidentally tested positive for SARS-CoV-2, while 37% were admitted for SARS-CoV-2 infection. Chronic underlying diseases were reported in 29.8% of children. The majority of children were asymptomatic or mildly symptomatic; only 12.7% developed a moderate to critical disease. A concomitant pathogen, mainly respiratory viruses, was isolated in 53.3%. Complications were reported in 7% of children admitted for other reasons and in 28.3% of those hospitalized for COVID-19. The respiratory system was most frequently involved, and the C-reactive protein was the laboratory test most related to the development of critical clinical complications. The main risk factors for complication development were prematurity [relative risk (RR) 3.8, 95% confidence interval (CI) 2.4-6.1], comorbidities (RR 4.5, 95% CI 3.3-5.6), and the presence of coinfections (RR 2.5, 95% CI 1.1-5.75). The OAS1/2/3 risk variant was the main genetic risk factor for pneumonia development [Odds ratio (OR) 3.28, 95% CI 1-10.7; p value 0.049].

CONCLUSION

Our study confirmed that COVID-19 is generally less severe in children, although complications can develop, especially in those with comorbidities (chronic diseases or prematurity) and coinfections. Variation at the OAS1/2/3 genes cluster is the main genetic risk factor predisposing to COVID-19 pneumonia in children.

Comparison of UK paediatric SARS-CoV-2 admissions across the first and second pandemic waves

BACKGROUND

We hypothesised that the clinical characteristics of hospitalised children and young people (CYP) with SARS-CoV-2 in the UK second wave (W2) would differ from the first wave (W1) due to the alpha variant (B.1.1.7), school reopening and relaxation of shielding.

METHODS

Prospective multicentre observational cohort study of patients <19 years hospitalised in the UK with SARS-CoV-2 between 17/01/20 and 31/01/21. Clinical characteristics were compared between W1 and W2 (W1 = 17/01/20-31/07/20,W2 = 01/08/20-31/01/21).

RESULTS

2044 CYP < 19 years from 187 hospitals. 427/2044 (20.6%) with asymptomatic/incidental SARS-CoV-2 were excluded from main analysis. 16.0% (248/1548) of symptomatic CYP were admitted to critical care and 0.8% (12/1504) died. 5.6% (91/1617) of symptomatic CYP had Multisystem Inflammatory Syndrome in Children (MIS-C). After excluding CYP with MIS-C, patients in W2 had lower Paediatric Early Warning Scores (PEWS, composite vital sign score), lower antibiotic use and less respiratory and cardiovascular support than W1. The proportion of CYP admitted to critical care was unchanged. 58.0% (938/1617) of symptomatic CYP had no reported comorbidity. Patients without co-morbidities were younger (42.4%, 398/938, <1 year), had lower PEWS, shorter length of stay and less respiratory support.

CONCLUSIONS

We found no evidence of increased disease severity in W2 vs W1. A large proportion of hospitalised CYP had no comorbidity.

IMPACT

No evidence of increased severity of COVID-19 admissions amongst children and young people (CYP) in the second vs first wave in the UK, despite changes in variant, relaxation of shielding and return to face-to-face schooling. CYP with no comorbidities made up a significant proportion of those admitted. However, they had shorter length of stays and lower treatment requirements than CYP with comorbidities once those with MIS-C were excluded. At least 20% of CYP admitted in this cohort had asymptomatic/incidental SARS-CoV-2 infection. This paper was presented to SAGE to inform CYP vaccination policy in the UK.

The Age-Related Course of COVID-19 in Pediatric Patients-1405 Cases in a Single Center

Since the beginning of the pandemic, many reports have pointed to age as the most important risk factor for severe COVID-19 in adults, but this relationship is less clear in children. Between March 2020 and April 2022, 1405 pediatric COVID-19 patients were included in our prospective study, which aimed to analyze the disease's characteristics in three age groups: infants, toddlers (1-5 years), and children (5-18 years). We observed male prevalence of the disease in infants and toddlers compared to female prevalence in children. Comorbidities appeared most often in children. In the first pandemic wave, the vast majority of pediatric patients were children, but later, the percentage of infant and toddler patients increased significantly. A total of 74% of hospitalized children were younger than five years. Upper respiratory tract symptoms were most common in infants and toddlers, and lower respiratory tract symptoms and gastroenterocolitis were more common in children. Neurological symptoms appeared similarly in all age groups. The activities of ALT, CK, and LDH were the most elevated in infants, along with D-dimers. The median length of hospitalization fluctuated between three and four days and was highest in infants. Severe courses were more common in adolescents.

The COVID-19 hospitalization metric in the pre- and postvaccination eras as a measure of pandemic severity: A retrospective, nationwide cohort study

BACKGROUND

Coronavirus disease 2019 (COVID-19) hospitalization definitions do not include a disease severity assessment. Thus, we sought to identify a simple and objective mechanism for identifying hospitalized severe cases and to measure the impact of vaccination on trends.

METHODS

All admissions to a Veterans' Affairs (VA) hospital, where routine inpatient screening is recommended, between March 1, 2020, and November 22, 2021, with laboratory-confirmed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) were included. Moderate-to-severe COVID-19 was defined as any oxygen supplementation or any oxygen saturation (SpO₂) <94% between 1 day before and 2 weeks after the positive SARS-CoV-2 test. Admissions with moderate-to-severe disease were divided by the total number of admissions, and the proportion of admissions with moderate-to-severe COVID-19 was modelled using a penalized spline in a Poisson regression and stratified by vaccination status. Dexamethasone receipt and its correlation with moderate-to-severe cases was also assessed.

RESULTS

Among 67,025 admissions with SARS-CoV-2, the proportion with hypoxemia or supplemental oxygen fell from 64% prior to vaccine availability to 56% by November 2021, driven in part by lower rates in vaccinated patients (vaccinated, 52% versus unvaccinated, 58%). The proportion of cases of moderate-to-severe disease identified using SpO₂ levels and oxygen supplementation was highly correlated with dexamethasone receipt (correlation coefficient, 0.95), and increased after July 1, 2021, concurrent with δ (delta) variant predominance.

CONCLUSIONS

A simple and objective definition of COVID-19 hospitalizations using SpO₂ levels and oxygen supplementation can be used to track pandemic severity. This metric could be used to identify risk factors for severe breakthrough infections, to guide clinical treatment algorithms, and to detect trends in changes in vaccine effectiveness over time and against new variants.

Predicting COVID-19 disease severity from SARS-CoV-2 spike protein sequence by mixed effects machine learning

Epidemiological studies show that COVID-19 variants-of-concern, like Delta and Omicron, pose different risks for severe disease, but they typically lack sequence-level information for the virus. Studies which do obtain viral genome sequences are generally limited in time, location, and population scope. Retrospective meta-analyses require time-consuming data extraction from heterogeneous formats and are limited to publicly available reports. Fortuitously, a subset of GISAID, the global SARS-CoV-2 sequence repository, includes "patient status" metadata that can indicate whether a sequence record is associated with mild or severe disease. While GISAID lacks data on comorbidities relevant to severity, such as obesity and chronic disease, it does include metadata for age and sex to use as additional attributes in modeling. With these caveats, previous efforts have demonstrated that genotype-patient status models can be fit to GISAID data, particularly when country-of-origin is used as an additional feature. But are these models robust and biologically meaningful? This paper shows that, in fact, temporal and geographic biases in sequences submitted to GISAID, as well as the evolving pandemic response, particularly reduction in severe disease due to vaccination, create complex issues for model development and interpretation. This paper poses a potential solution: efficient mixed effects machine learning using GPBoost, treating country as a random effect group. Training and validation using temporally split GISAID data and emerging Omicron variants demonstrates that GPBoost models are more predictive of the impact of spike protein mutations on patient outcomes than fixed effect XGBoost, LightGBM, random forests, and elastic net logistic regression models.

COVID ‐19 in New South Wales children during 2021: severity and clinical spectrum

Objectives: To describe the severity and clinical spectrum of coronavirus disease 2019 (COVID‐19) in children during the 2021 New South Wales outbreak of the Delta variant of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2).

Design, setting: Prospective cohort study in three metropolitan Sydney local health districts, 1 June – 31 October 2021.

Participants: Children under 16 years of age with positive SARS‐CoV‐2 nucleic acid test results admitted to hospital or managed by the Sydney Children’s Hospital Network (SCHN) virtual care team.

Main outcome measures: Age‐specific SARS‐CoV‐2 infection frequency, overall and separately for SCHN virtual and hospital patients; rates of medical and social reason admissions, intensive care admissions, and paediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2 per 100 SARS‐CoV‐2 infections; demographic and clinical factors that influenced likelihood of hospital admission.

Results: A total of 17 474 SARS‐CoV‐2 infections in children under 16 were recorded in NSW, of whom 11 985 (68.6%) received SCHN‐coordinated care, including 459 admitted to SCHN hospitals: 165 for medical reasons (1.38 [95% CI, 1.17–1.59] per 100 infections), including 15 admitted to intensive care, and 294 (under 18 years of age) for social reasons (2.45 [95% CI, 2.18–2.73] per 100 infections). In an analysis that included all children admitted to hospital and a random sample of those managed by the virtual team, having another medical condition (adjusted odds ratio [aOR], 7.42; 95% CI, 3.08–19.3) was associated with increased likelihood of medical admission; in univariate analyses, non‐asthmatic chronic respiratory disease was associated with greater (OR, 9.21; 95% CI, 1.61–174) and asthma/viral induced wheeze with lower likelihood of admission (OR, 0.38; 95% CI, 0.18–0.78). The likelihood of admission for medical reasons declined from infancy to 5–11 years, but rose again for those aged 12–15 years. Sex and Indigenous status did not influence the likelihood of admission.

Conclusion: Most SARS‐CoV‐2 infections (Delta variant) in children were asymptomatic or associated with mild disease. Hospitalisation was relatively infrequent, and most common for infants, adolescents, and children with other medical conditions. More children were hospitalised for social than for medical reasons.

The known: Information regarding disease severity and reasons for hospital admissions of children with COVID‐19 in Australia is very limited.

The new: In 2021, more NSW children with SARS‐CoV‐2 infections were hospitalised for social or welfare reasons (294, 64%; 2.45 per 100 infections) than for medical treatment (165, 36%; 1.38 per 100 infections). Children under six months of age, aged 12–15 years, or with another medical condition were more likely to be hospitalised than other children.

The implications: As acute COVID‐19 is typically mild in children, measures that protect them from SARS‐CoV‐2 but harm their overall wellbeing may be disproportionate. Community support for children with special care needs could reduce the number of hospitalisations.

Clinical and epidemiological characteristics of SARS-CoV-2 Infection in Los Angeles County youth during the first year of the pandemic

OBJECTIVES

The aim of this study was to characterize SARS-CoV-2 infection patterns in Los Angeles (LA) County youth followed at our institution during the first pandemic year.

DESIGN

A prospective cohort of patients aged < 25 years who tested positive for SARS-CoV-2 using reverse-transcriptase polymerase chain reaction (RT-PCR) assays between March 13, 2020, and March 31, 2021, was evaluated at a large LA County health network. Demographics, age distribution, and disease severity were analyzed.

RESULTS

There were 28,088 youth aged < 25 years tested for SARS-CoV-2 using RT-PCR, with 1849 positive results identified (7%). Among the positive results, 475 of 11,922 (4%) were identified at the pandemic onset (March-September 2020) (Cohort 1) and 1374 of 16,166 (9%) between October 2020 and March 2021 (Cohort 2), P < 0.001. When disease severity was compared across cohorts, Cohort 2 had a greater proportion of asymptomatic and mild/moderate disease categories than Cohort 1 (98% vs 80%, respectively); conversely, Cohort 1 had a near-10-fold higher proportion of severe disease than Cohort 2 (17% vs 1.8%). Cohort 2 comprised younger patients with a mean age of 13.7 years vs 17.3 years in Cohort 1. Older age was associated with a higher percentage of infection, with 63% of all confirmed cases found in participants aged 19 to 25 years in Cohort 1, compared with 38% of confirmed cases in Cohort 2. Age increase was also associated with greater disease severity by linear regression modeling (P< 0.001).

CONCLUSION

Coronavirus disease 2019 (COVID-19) disease severity in youth decreased over time in LA County during the first pandemic year, likely a reflection of changing demographics, with younger children infected. A higher infection rate in youth did not lead to higher disease severity over time.

Hierarchy of Evidence Within the Medical Literature

The quality of evidence from medical research is partially deemed by the hierarchy of study designs. On the lowest level, the hierarchy of study designs begins with animal and translational studies and expert opinion, and then ascends to descriptive case reports or case series, followed by analytic observational designs such as cohort studies, then randomized controlled trials, and finally systematic reviews and meta-analyses as the highest quality evidence. This hierarchy of evidence in the medical literature is a foundational concept for pediatric hospitalists, given its relevance to key steps of evidence-based practice, including efficient literature searches and prioritization of the highest-quality designs for critical appraisal, to address clinical questions. Consideration of the hierarchy of evidence can also aid researchers in designing new studies by helping them determine the next level of evidence needed to improve upon the quality of currently available evidence. Although the concept of the hierarchy of evidence should be taken into consideration for clinical and research purposes, it is important to put this into context of individual study limitations through meticulous critical appraisal of individual articles.

Insights in paediatric virology during the COVID-19 era (Review)

The present article provides an overview of the key messages of the topics discussed at the '7th Workshop on Paediatric Virology', which was organised virtually on December 20, 2021 by the Institute of Paediatric Virology, located on the Island of Euboea in Greece. The workshop's plenary lectures were on: i) viral pandemics and epidemics in the ancient Mediterranean; ii) the impact of obesity on the outcome of viral infections in children and adolescents; and iii) COVID-19 and artificial intelligence. Despite the scarcity of evidence from fossils and remnants, viruses have been recognised as significant causes of several epidemics in the ancient Mediterranean. Paediatric obesity, a modifiable critical health risk factor, has been shown to impact on the development, progression and severity of viral infections. Thus, the prevention of paediatric obesity should be included in formulating public health policies and decision-making strategies against emerging global viral threats. During the current COVID-19 pandemic, artificial intelligence has been used to facilitate the identification, monitoring and prevention of SARS-CoV-2. In the future, it will play a fundamental role in the surveillance of epidemic-prone infectious diseases, in the repurposing of older therapies and in the design of novel therapeutic agents against viral infections. The collaboration between different medical specialties and other diverse scientific fields, including archaeology, history, epidemiology, nutritional technologies, mathematics, computer technology, engineering, medical law and ethics is essential for the successful management of paediatric viral infections. The current COVID-19 pandemic has underscored this need, which should be further encouraged in modern medical education.

BNT162b2 Vaccine-Associated Myo/Pericarditis in Adolescents: A Stratified Risk-Benefit Analysis

BACKGROUND

Male patients ages 12-17 years have an elevated risk of mRNA vaccination-associated myo/pericarditis. A risk-benefit analysis of first and second doses of mRNA vaccination in adolescent boys by health status and history of SARS-CoV-2 infection has not been performed.

METHODS

Using the Vaccine Adverse Event Reporting System (VAERS), we identified BNT162b2 [Pfizer-BioNTech] myo/pericarditis occurrence according to CDC criteria. Main outcomes were as follows: 1) post-vaccination myo/pericarditis crude incidence in adolescents aged 12-15 and 16-17; and 2) two risk-benefit analyses by age, sex, comorbidity, variant and history of infection.

RESULTS

Cases of myo/pericarditis (n = 253) included 129 after dose 1 and 124 after dose 2; 86.9% were hospitalized. Incidence per million after dose two in male patients aged 12-15 and 16-17 was 162.2 and 93.0, respectively. Weighing post-vaccination myo/pericarditis against COVID-19 hospitalization during delta, our risk-benefit analysis suggests that among 12-17-year-olds, two-dose vaccination was uniformly favourable only in nonimmune girls with a comorbidity. In boys with prior infection and no comorbidities, even one dose carried more risk than benefit according to international estimates. In the setting of omicron, one dose may be protective in nonimmune children, but dose two does not appear to confer additional benefit at a population level.

CONCLUSIONS

Our findings strongly support individualized paediatric COVID-19 vaccination strategies which weigh protection against severe disease vs. risks of vaccine-associated myo/pericarditis. Research is needed into the nature and implications of this adverse effect as well as immunization strategies which reduce harms in this overall low-risk cohort.

The Impact of Obesity on Disease Severity and Outcomes Among Hospitalized Children With COVID-19

OBJECTIVE

To describe the impact of obesity on disease severity and outcomes of coronavirus disease 2019 (COVID-19) among hospitalized children.

METHODS

This retrospective cohort study from the Society of Critical Care Medicine Viral Respiratory Illness Universal Study registry included all children hospitalized with COVID-19 from March 2020 to January 2021. Obesity was defined by Centers for Disease Control and Prevention BMI or World Health Organization weight for length criteria. Critical illness definition was adapted from National Institutes of Health criteria of critical COVID. Multivariate mixed logistic and linear regression was performed to calculate the adjusted odds ratio of critical illness and the adjusted impact of obesity on hospital length of stay.

RESULTS

Data from 795 patients (96.4% United States) from 45 sites were analyzed, including 251 (31.5%) with obesity and 544 (68.5%) without. A higher proportion of patients with obesity were adolescents, of Hispanic ethnicity, and had other comorbidities. Those with obesity were also more likely to be diagnosed with multisystem inflammatory syndrome in children (35.7% vs 28.1%, P = .04) and had higher ICU admission rates (57% vs 44%, P < .01) with more critical illness (30.3% vs 18.3%, P < .01). Obesity had more impact on acute COVID-19 severity than on multisystem inflammatory syndrome in children presentation. The adjusted odds ratio for critical illness with obesity was 3.11 (95% confidence interval: 1.8-5.3). Patients with obesity had longer adjusted length of stay (exponentiated parameter estimate 1.3; 95% confidence interval: 1.1-1.5) compared with patients without obesity but did not have increased mortality risk due to COVID-19 (2.4% vs 1.5%, P = .38).

CONCLUSION

In a large, multicenter cohort, a high proportion of hospitalized children from COVID-19 had obesity as comorbidity. Furthermore, obesity had a significant independent association with critical illness.

The impact of the COVID-19 pandemic on child health

Most Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections in children are mild or asymptomatic. Severe Coronavirus Disease 2019 (COVID-19) in children is infrequent. An estimated 0.3–1.3% of children with SARS-CoV-2 infection were admitted to hospital, and of these 13–23% needed critical care. SARS-CoV-2 related deaths were very rare in children, estimated at 2 per million. The vast majority of admitted children had one of shortness of breath, fever, and cough, but atypical symptoms are more common in children. Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) have been linked to SARS-CoV-2 infection. Cardinal symptoms include prolonged fever, clinical signs of inflammation, gastro-intestinal symptoms, and cardiac dysfunction. Twenty two to 80% of patients with MIS-C needed critical care; mortality of MIS-C is around 2%. Six to 24% of children with MIS-C had coronary artery dilatation or cardiac aneurysms. Equipoise still exists between first-line treatment with immunoglobulins and steroids. Outcomes for children with MIS-C are generally very good in those recognised early and started on appropriate treatment. Vaccination schemes for children are rapidly expanding, with the benefits of preventing severe COVID-19 disease and MIS-C and reducing community transmission outweighing the risks of adverse events of, amongst others, myocarditis temporally related to COVID-19 vaccination in children and young adults. The imposed social distancing measures reduced the overall number of children with acute illness or injury presenting to urgent and emergency care facilities worldwide. No clear signal was seen that large numbers of children had a delayed presentation to emergency care departments with a serious illness. The social distancing measures negatively impacted the mental health of children.