COVID-19 disease in children presenting to the pediatric emergency department: A multicenter study with 8886 cases from Turkey

Background

The aim was to evaluate the epidemiological, clinical, laboratory, and radiologic data of children with SARS-CoV-2 positivity by polymerase chain reaction (PCR) together with treatment strategies and clinical outcomes and to evaluate cases of multisystem inflammatory syndrome in children (MIS-C) in this population.

Methods

This was a multicenter retrospective observational cohort study performed in the pediatric emergency departments of 19 tertiary hospitals. From March 11, 2020, to May 31, 2021, children who were diagnosed with confirmed nasopharyngeal/tracheal specimen SARS-CoV-2 PCR positivity or positivity for serum-specific antibodies against SARS-CoV-2 were included. Demographics, presence of chronic illness, symptoms, history of contact with SARS-CoV-2 PCR-positive individuals, laboratory and radiologic investigations, clinical severity, hospital admissions, and prognosis were recorded.

Results

A total of 8886 cases were included. While 8799 (99.0%) cases resulted in a diagnosis of SARS-CoV-2 with PCR positivity, 87 (1.0%) patients were diagnosed with MIS-C. Among SARS-CoV-2 PCR-positive patients, 51.0% were male and 8.5% had chronic illnesses. The median age was 11.6 years (IQR: 5.0–15.4) and 737 (8.4%) patients were aged <1 year. Of the patients, 15.5% were asymptomatic. The most common symptoms were fever (48.5%) and cough (30.7%) for all age groups. There was a decrease in the rate of fever as age increased (p < 0.001); the most common age group for this symptom was <1 year with the rate of 69.6%. There was known contact with a SARS-CoV-2 PCR-positive individual in 67.3% of the cases, with household contacts in 71.3% of those cases. In terms of clinical severity, 83 (0.9%) patients were in the severe-critical group. There was hospital admission in 1269 (14.4%) cases, with 106 (1.2%) of those patients being admitted to the pediatric intensive care unit (PICU). Among patients with MIS-C, 60.9% were male and the median age was 6.4 years (IQR: 3.9–10.4). Twelve (13.7%) patients presented with shock. There was hospital admission in 89.7% of these cases, with 29.9% of the patients with MIS-C being admitted to the PICU.

Conclusion

Most SARS-CoV-2 PCR-positive patients presented with a mild clinical course. Although rare, MIS-C emerges as a serious consequence with frequent PICU admission. Further understanding of the characteristics of COVID-19 disease could provide insights and guide the development of therapeutic strategies for target groups.

Do Pediatric Emergency Physicians Comply With Guideline Recommendations in Management of Patients With Acute Urticaria?

OBJECTIVES

To determine the level of knowledge and practical preferences of pediatricians regarding acute urticaria (AU) management and to assess the effects of training provided in accordance with the current urticaria guideline recommendations on pediatricians who work in the pediatric emergency department (PED).

METHODS

A theoretical training was provided to pediatricians regarding the diagnosis and treatment of AU in line with current urticaria guideline recommendations. Before the training, pediatricians completed a 10-item questionnaire. This prospective study assesses their treatment approaches in patients admitted to PED because of AU during the 6-month period before and the 1-year period after training.

RESULTS

Four hundred seventeen children in the pretraining and 1085 children in the posttraining periods were treated for AU in PED. Forty-eight pediatricians participated in the training. According to their questionnaire responses, 35% of them used only H1 antihistamine (AH) treatment, 50% used second-generation H1 AH (2nd-GAH) as AHs, 75% preferred the oral route of administration, and 85.4% did not administer systemic corticosteroid (sCS) to all patients. Comparing the practice approaches of the pediatricians in the pretraining and posttraining periods, first-generation H1 antihistamine (1st-GAH) preference rate decreased from 68.4% to 30.3% and the sCS preference rate decreased from 58.5% to 25.7%, while the 2nd-GAH preference rate increased from 31.7% to 69.7% (P < 0.001 for all). No treatments were prescribed for 10.8% of patients before the training and 3% after the training during discharge at home (P < 0.05). Comparing the home treatment choices of the pediatricians in the pretraining and posttraining periods, 1st-GAH preference rate decreased from 11.5% to 5%, while the 2nd-GAH preference rate increased from 78.7% to 91.5% (for both parameters, P < 0.001).

CONCLUSIONS

Practical treatment preferences of pediatricians in the treatment of children with AU differ considerably from both current guideline recommendations and their own theoretical knowledge, and training can enhance pediatricians' compliance with current guideline recommendations.

Epidemiological, Clinical, and Laboratory Features of Children With COVID-19 in Turkey

Objectives: The aim of this study is to identify the epidemiological, clinical, and laboratory features of coronavirus disease 2019 (COVID-19) in children. Methods: A retrospective study was conducted by pediatric infectious disease specialists from 32 different hospitals from all over Turkey by case record forms. Pediatric cases who were diagnosed as COVID-19 between March 16, 2020, and June 15, 2020 were included. Case characteristics including age, sex, dates of disease onset and diagnosis, family, and contact information were recorded. Clinical data, including the duration and severity of symptoms, were also collected. Laboratory parameters like biochemical tests and complete blood count, chest X-ray, and chest computed tomography (CT) were determined. Results: There were 1,156 confirmed pediatric COVID-19 cases. In total, male cases constituted 50.3% (n = 582) and females constituted 49.7% (n = 574). The median age of the confirmed cases was 10.75 years (4.5-14.6). Of the total cases, 90 were younger than 1 year of age (7.8%), 108 were 1-3 years of age (9.3%), 148 were 3-6 years of age (12.8%), 298 were 6-12 years of age (25.8%), 233 were 12-15 years of age (20.2%), and 268 cases were older than 15 years of age (23.2%). The most common symptom of the patients at the first visit was fever (50.4%) (n = 583) for a median of 2 days (IQR: 1-3 days). Fever was median at 38.4°C (38.0-38.7°C). The second most common symptom was cough (n = 543, 46.9%). The other common symptoms were sore throat (n = 143, 12.4%), myalgia (n = 141, 12.2%), dyspnea (n = 118, 10.2%), diarrhea (n = 112, 9.7%), stomachache (n = 71, 6.1%), and nasal discharge (n = 63, 5.4%). When patients were classified according to disease severity, 263 (22.7%) patients were asymptomatic, 668 (57.7%) patients had mild disease, 209 (18.1%) had moderate disease, and 16 (1.5%) cases had severe disease. One hundred and forty-nine (12.9%) cases had underlying diseases among the total cases; 56% of the patients who had severe disease had an underlying condition (p < 0.01). The need for hospitalization did not differ between patients who had an underlying condition and those who do not have (p = 0.38), but the need for intensive care was higher in patients who had an underlying condition (p < 0.01). Forty-seven (31.5%) of the cases having underlying conditions had asthma or lung disease (38 of them had asthma). Conclusions: To the best of our knowledge, this is one of the largest pediatric data about confirmed COVID-19 cases. Children from all ages appear to be susceptible to COVID-19, and there is a significant difference in symptomatology and laboratory findings by means of age distribution.

Efficacy and safety profile of intravenous levetiracetam versus phenytoin in convulsive status epilepticus and acute repetitive seizures in children

PURPOSE

Although phenytoin is one of the most commonly used antiepileptic drugs (AEDs), it has potential serious side effects and drug interactions. Levetiracetam is a relatively newer AED with favorable pharmacokinetics and could be an effective and safer option for the treatment of convulsive status epilepticus (CSE). We aimed to compare the efficacy and safety profile of intravenous levetiracetam and phenytoin as second-line treatment agents in children with CSE and acute repetitive seizures (ARS).

METHOD

Two hundred seventy-seven patients aged between 1 month and 18 years who received intravenous levetiracetam or phenytoin as a second-line AED with the diagnosis of CSE or ARS were retrospectively evaluated. Drug efficacy was defined as control of seizures without the need for any additional medication after completion of the infusion and no recurrence in the following 12 h. The primary outcome was drug efficacy. The secondary outcomes included application of an additional second-line AED, induction of anesthesia, and admission to the intensive care unit (ICU), and drug-related adverse reactions.

RESULTS

No differences were found between the two treatment groups with regard to patient characteristics and seizure type. The efficacy of levetiracetam was higher than that of phenytoin (77.6% vs 57.7%, P = 0.011) in children with CSE. There was no significant difference between the efficacy rates of levetiracetam and phenytoin for ARS (55.8% vs 58.8%, P = 0.791). Overall, drug efficacy was 70.9% for levetiracetam and 58.1% for phenytoin (P = 0.048). For CSE, the need for additional second-line treatment, anesthesia induction, and ICU admission was higher in the phenytoin group (P = 0.001, P = 0.038, P = 0.02, respectively). Drug-related adverse reactions were more frequent in the phenytoin group than the levetiracetam group (23.3% vs 1.4%; P < 0.001). The most common adverse reaction in the phenytoin group was hypotension. Phenytoin-related anaphylaxis was detected in one patient. No serious adverse effects related to levetiracetam were observed.

CONCLUSIONS

Intravenous levetiracetam seems as effective as intravenous phenytoin in emergency treatment of children with ARS and more effective for CSE in stopping the seizure with less risk of recurrence. Levetiracetam has fewer cardiovascular side effects and has a safer profile than phenytoin. Intravenous levetiracetam is a favorable option as a first second-line AED for pediatric seizures.

Long-term Effects of Indirect Hyperbilirubinemia on Auditory and Neurological Functions in Term Newborns

Objective:

The aim of this study was to investigate the long-term effects of hyperbilirubinemia on neurological and hearing function in otherwise healthy term newborns with neonatal indirect hyperbilirubinemia.

Method:

This study was performed prospectively in 41 term newborns hospitalized for indirect hyperbilirubinemia. Patients with no signs of hemolysis were categorized in 3 groups based on stabil levels as sTB <20 mg/dl, 20-24.9 mg/dl, and =>25 mg/dl. Patients with total bilirubin level =>20 mg/dl and hemolytic disease were classified as the fourth group. The relationship between maximum sTB level, duration of exposure to sTB levels >20 mg/dl and etiology of jaundice with neurological and auditory functions was investigated. Detailed neurological examination, Denver II developmental screening test and hearing tests (otoacoustic emissions, OAE and auditory brainstem responses, ABR) were performed to all patients between 18-24 months of age.

Results:

Neurodevelopmental disorder was found in 5 (12.2%) patients. Hemolytic disease was detected in two of these patients. Hearing loss was found in 4 (9.8%) of the patients. Two of these patients had auditory neuropathy spectrum disorder and the other two had cochlear hearing loss. The sTB levels of all these patients were above 25 mg/dl. No neurological disorder or hearing loss was found in the patients who had stabil of <25 mg/dl. Exposure time to sTB levels above 20 mg/dl was significantly longer in patients with neurological dysfunction and pathologic ABR results (p:0.007, p:0.007; p<0.05).

Conclusion:

This study demonstrates that kernicterus may develop in term newborns with severe hyperbilirubinemia (sTB>25 mg/dl) without any finding of significant hemolysis. Not only the bilirubin level but also the duration of exposure to high bilirubin levels may be effective in the development of bilirubin neurotoxicity. The high rate of hearing loss in our patients emphasizes the importance of screening for infants with severe hyperbilirubinemia using comprehensive auditory evaluation for early diagnosis of possible hearing loss.

Acute aortic dissection mimicking acute abdomen in a 14-year-old boy

Aortic dissection is extremely rare in children. Although it usually presents with severe chest pain, atypical clinical presentations mimicking various illnesses may cause misdiagnosis. In this report, the case of a 14-year-old boy with symptoms suggestive of acute abdomen, which was finally diagnosed as aortic dissection, is discussed.

The evaluation of risk factors for recurrent hospitalizations resulting from wheezing attacks in preschool children

BACKGROUND

We aimed to evaluate the risk factors in preschool children admitted to inpatient services with a diagnosis of recurrent attacks of wheezing.

METHOD

The medical files of 44 preschool children with 2 or more recurrent hospitalizations resulting from wheezing between November 2011 and January 2012 were retrospectively investigated.

RESULTS

There were 28 males (64 %) and 16 females. The median age was 14 months (2.0-50). The median numbers of previous wheezing attacks and hospitalizations were 4 (2-10) and 2 (2-8), respectively. Fourteen patients (32 %) had been treated for gastroesophageal reflux (GER). The previous and recent hospital evaluations were investigated. Bronchopulmonary dysplasia and anemia were significantly more common in patients with 3 or more hospitalizations for wheezing than in those with 2 hospitalizations (p = 0.010 and p < 0.001, respectively). A review of the cases with 3 or more hospitalizations revealed that a history of GER and anemia were significant risk factors.

CONCLUSION

Anemia and GER are risk factors for recurrent hospitalizations resulting from wheezing and should be treated. If the history and physical examination suggest asthma, inhaler therapy treatment should be administered, with other investigations planned for patients who do not respond to treatment as expected.

A rare cause of upper airway obstruction: isolated demyelinating brainstem lesion

Acute upper airway obstruction derived from any cause can be a life-threatening emergency in pediatric patients. The major causes are infection, foreign body aspiration, and trauma. However, acute neurological disorders occasionally may manifest as severe airway obstruction.In our case, we report a 10-year-old patient presenting with prominent upper airway obstruction requiring intubation and respiratory support. He also had fever, encephalopathy, and involvement of multiple cranial nerves. Cranial magnetic resonance imaging showed a hyperintense lesion covering all of the medulla oblongata on T2-weighted images and a lesion that was hypointense on T1-weighted images with no enhancement. Diffusion maps were normal. High-dose steroids and then intravenous immunoglobulin were given because these findings were mostly consistent with an inflammatory demyelinating process in the brainstem. A dramatic improvement was observed, and he was extubated on the 10th day. He completely recovered within 3 weeks without any neurological deficit.We emphasize that emergency physicians should be familiar with the airway manifestations of acute neurological disorders. Although rare, acute demyelinating brainstem disorders should be considered a part of the differential diagnosis of upper airway obstruction in children. Prompt recognition of this entity in light of additional neurological findings, neuroimaging, and other laboratory test results is critical. Early immunomodulatory treatment of these patients can be lifesaving.

Status epilepticus in children: causes, clinical features and short-term outcome

BACKGROUND

We aimed to evaluate the cause, clinical profile, and short-term outcome of status epilepticus cases that were admitted to our pediatric emergency unit between 1 January and 31 December 2008.

METHODS

We studied the clinical features of 59 seizures that occurred in 56 patients aged between 3 months and 15 years with the diagnosis of status epilepticus. We observed the clinical course and outcome of 53 cases for 6 to 18 months. The correlation between the cause of the seizure and the patient's age at the time of status epilepticus was evaluated as well as the correlation between the risk of seizure recurrence and family history of seizure, the neurological status of the patient prior to seizure and the presence of epilepsy.

RESULTS

The most common cause of status epilepticus is febrile illness in children younger than 2 years and idiopathic/cryptogenic and remote symptomatic causes in children older than 2 years. The rate of recurrence of seizure was significantly higher in cases with existing neurological abnormalities, prior epilepsy and seizures with remote symptomatic causes. The most common triggering factors of status epilepticus development in cases with epilepsy were noncompliance for anti-epileptic drugs and infectious fever.

CONCLUSIONS

In our study, the risk factors for seizure recurrence were the presence of prior epilepsy, existence of neurological abnormalities and remote symptomatic causes. We argue that improving the compliance of patients and their families to take medicine appropriately and training them in how to cope with febrile illnesses may decrease the recurrence of seizures.