COVID-19 Infection in Children

Dr. Shamsur Chowdhury March 20, 2020 coronaviruses, COVID-19, SARS-CoV2

I was given the opportunity to write a brief summary of novel corona viral infection in children. Even though I have no personal experience taking care of any child with this particular infection, however, as a pediatric intensivist I have managed children with other viral infections who get as sick as those who are inflicted with COVID-19 and require ICU admission and management. While COVID-19 is a new entity, management principle remains the same as managing other critical viral infections although the course of this disease, specific management options and outcome are still uncertain.

In this presentation, I will try to shed some lights on what we know so far about this novel viral infection in children in a question-answer format to make it easier for our readers to follow. I’ll use various online resources including but not limited to CDC website, AAP (American Academy of Pediatrics) and review some studies from China.

What is COVID-19:

COVID-19 is the abbreviated name for the disease caused by a novel corona virus named “SARS-CoV-2” in 2019.

Coronaviruses are common to both human and animals, and rarely, animal corona virus can infect human that subsequently will spread from human to human. Even though first few infections were identified on patients who visited a particular fish market, subsequent cases were to be transmitted from infected human, children were infected through their adult care giver.

Three corona viral infection in human (MERS-CoV, SARS-CoV, and new SARS-CoV2) are thought to have first originated from bats.

How COVID-19 Spreads:

I was given the opportunity to write a brief summary of novel corona viral infection in children. Even though I have no personal experience taking care of any child with this particular infection, however, as a pediatric intensivist I have managed children with other viral infections who get as sick as those who are inflicted with COVID-19 and require ICU admission and management. While COVID-19 is a new entity, management principle remains the same as managing other critical viral infections although the course of this disease, specific management options and outcome are still uncertain.

In this presentation, I will try to shed some lights on what we know so far about this novel viral infection in children in a question-answer format to make it easier for our readers to follow. I’ll use various online resources including but not limited to CDC website, AAP (American Academy of Pediatrics) and review some studies from China.

• Most contagious when people are most symptomatic (the sickest), but some spread might be possible before people show any symptoms;
What are the sign/ symptoms and what are the outcome of Children with COVID-19 infection:

Due to the paucity of data on COVID-19 infection in children in USA, I’ll present findings from few publications that describe experience in China.

  1. SARS-CoV-2 Infection in Children; Lu et al.;Wuhan, China (Published as a letter to the editor, March 18, 2020, at NEJM.org)
    • 1391 children assessed and tested (Jan 28 –Feb 26, 2020)
    • 171 (12.3%) confirmed to have SARS-CoV2 infection
    • Age: 1 day-15 years; Median Age-6.7 years
    • No symptoms/No radiologic changes: 27 patients (15.8%)
    • Fever -41.5% , other symptoms –cough, pharyngeal erythema
    • 3/171 required intensive care admission and mechanical ventilation; all had coexisting conditions
    • Common radiologic findings (32.7%)- bilateral groundglass opacity
    • Outcome: 1 death (10m. old with intussusception and MOF)
      21 stable in general ward
      149 discharged out of hospital alive
    • Link to further reading: https://www.nejm.org/doi/full/10.1056/NEJMc2005073
  2. Detection of Covid-19 in Children in Early January 2020 in Wuhan, China; Liu et al.
    (Published as a letter to the editor on March 12, 2020, at NEJM.org.)
    • Retrospective study, 366 hospitalized children (≤16 years of age), Jan 7-15;
    • 6 children diagnosed with SAR-CoV-2 (1.6%)
    • Symptoms: high fever (>39°C) (all 6), cough (in all six), and vomiting (in four).
    • 1 needed admission to PICU,
    • 100% survival
Link for further reading: https://www.nejm.org/doi/full/10.1056/NEJMc2003717

3. Epidemiology of COVID-19 Among Children in China; Tong et al.; Pediatrics. 2020 (Pre-publication)

  • 2143 children with COVID-19 reported to Chinese CDC
  • 731 (34.1%) laboratory-confirmed cases and
  • 1412 (65.9%)-suspected (?)
  • 4% of children were asymptomatic,
  • 51% had mild illness
  • 39% had moderate illness
  • 6% had severe or critical illness, (compared to 18.5% of adults)
  • 1 death (a 14-year-old boy),
  • infants and younger kids (<1 yr) had higher rates of critical cases (11%) compared to older children (3% for 16yrs and older)
Presentation Based on Severity: (Tong et al)

Mild (51%): URI symptoms (fever ±, cough, myalgia, sore throat), GI symptoms

Moderate (39%): pneumonia (fever/ cough), minimal hypoxemia, positive CT scan

Severe (6%): Early fever/ cough ± GI symptoms (diarrhea) for about a week, progresses to dyspnea, hypoxia

Critical (6%): progresses to ARDS or respiratory failure, and may also have shock, encephalopathy, myocardial injury/ heart failure, coagulation dysfunction, and acute kidney injury. Organ dysfunction can be life threatening

Links to further reading: https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020

Why most of the COVID-19 cases in children were less severe than adults?
  • Related to both exposure and host factors
  • Angiotensin converting enzyme II (ACE2), cell receptor for SARS-CoV, is less sensitive and less mature in children than adults (Tong et al.)
  • Children often experience more respiratory viral infections and may have higher levels of antibody against virus than adults (Tong et al.)
How can I differentiate COVID-19 from other Viral Illnesses:
( Source: Mobeen Rathore, MD; COVID-19 Webinar, Wolfson Children’s Hospital)
Course of the COVID-19 Illness: (From Zunyou Wu, Chinese CDC; copied from COVID-19 Webinar-2, by Mobeen Rathore, MD and others, UF Jax)

How Can I Find Out if I have COVID-19?

Criteria to Guide Evaluation and Laboratory Testing for COVID-19 for Clinicians:
  • Clinicians should work with their local and state health departments to coordinate testing through public health laboratories.
  • Determine if a patient has signs and symptoms compatible with COVID-19 and whether not to be tested.
  • Sign/symptoms consistent with COVID-19 include fever, and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).
Priorities for testing may include:
  • Hospitalized patients with signs/ symptoms compatible with COVID-19 for infection control purposes.
  • symptomatic older adults and those with chronic medical conditions and/or an immunocompromised state at higher risk for poor outcomes (e.g., diabetes, heart disease, chronic lung and kidney disease).
  • Any persons including healthcare personnel, who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient, or who have a history of travel from areas/countries with COVID-19 infection within 14 days of their symptom onset.
  • For initial diagnostic testing for COVID-19, CDC recommends collecting and testing upper respiratory tract specimens (nasopharyngeal swab). CDC also recommends testing lower respiratory tract specimens, if available.
Management:
  • Treatment is symptomatic and supportive
  • Insufficient data on efficacy of any specific antiviral agent in children
  • One child was treated with IVIG in china (Liu et al).
  • Multiple investigational agents are being used in adults with COVID-19 infection, efficacy still unknown in Children (Source: Uptodate)
  • –Remdisivir: A nucleotide analogue that has activity against SARS-CoV-2 in vitro
  • –Chloroquin/Hydroxychloroquin: Both inhibit SARS-CoV-2, study in progress;
  • –Lopinavir/ Ritonavir: Combined protease inhibitor, primarily been used for HIV infection, has in vitro activity against the SARS-CoV/ MERS-CoV
  • –Tocilizumab: An IL-6 inhibitor, being used in China on patients with COVID-19 and elevated IL-6
  • Favipiravir (Avigan): An anti-viral agent used for influenza infection in Japan, showed positive outcomes in clinical trials in China.

Talking to children about COVID-19: (Source: CDC)

  • Remain calm and reassuring.
  • Make yourself available to listen and to talk.
  • Avoid language that might blame others and lead to stigma
  • Pay attention to what children see or hear on television or online
  • Provide information that is honest and accurate.
  • Teach children everyday actions to reduce the spread of germs.

Facts about COVID-19 for discussions with children

Try to keep information simple when talking about COVID-19 infection:

What is COVID-19:
  • COVID-19 is the short name for “coronavirus disease 2019.” It is a new virus that made a lot of people sick.
  • Scientists and doctors think that most people will be ok, especially kids, but some people might get pretty sick.
  • Doctors and health experts are working hard to help people stay healthy.
What can I do so that I don’t get COVID-19?
You can practice healthy habits at home, school, & play to help protect against the spread of COVID-19:
  • Cough or sneeze into a tissue or your elbow. If you sneeze or cough into a tissue, throw it in the trash right away.
  • Keep your hands out of your mouth, nose, and eyes. This will help keep germs out of your body.
  • Wash your hands with soap and water for at least 20 seconds.
Follow these five steps—wet, lather (make bubbles), rub together, rinse and dry
You can sing the “Happy Birthday” song twice.
  • If you don’t have soap and water, have an adult help you use a hand cleaner.
  • Keep things clean.
  • If you feel sick, stay home. Just like you don’t want to get other people’s germs in your body, other people don’t want to get your germs either.
What can I do so that I don’t get COVID-19?
  • COVID-19 can look different in different people. For many people, being sick with COVID-19 would be a little bit like having the flu.
  • People can get a fever, cough, or have a hard time taking deep breaths.
  • From what doctors have seen so far, most children don’t seem to get very sick. While a lot of adults get sick, most adults get better.
  • If you do get sick, it doesn’t mean you have COVID-19. People can get sick from all kinds of germs. What’s important to remember is that if you do get sick, the adults at home and school will help get you any help that you need.

References:
1. CDC.gov
2. AAP.org
3. COVID-19 Webinar-2, by Mobeen Rathore, MD and others, UF Jcksonville)
4. Uptodate.com
5. Epidemiology of COVID-19 Among Children in China; S. Tong et al.; Pediatrics. 2020 (Pre-publication)
6. Detection of Covid-19 in Children in Early January 2020 in Wuhan, China; W. Liu et al. Letter to the editor on March 12, 2020, at NEJM.org.
7. SARS-CoV-2 Infection in Children; Lu et al.;
(Published as a letter to the editor, March 18, 2020, at NEJM.org)

Shamsur Chowdhury, MD

Dr. Shamsur Chowdhury, MD, MS, is trained in Pediatrics, Pediatric Critical Care and Pediatric Cardiac Critical Care AND currently working as a Cardiac Intensivist at Wolfson Children’s Hospital, Jacksonville, Florida. He is also a Clinical Assistant Professor of Department of Critical Care Medicine at University of Pittsburgh.