Acute COVID management in children – evidence summary

Cite this article as:
Michaela Waak + Cameron Graydon. Acute COVID management in children – evidence summary, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25071

This post is a rapid review of pertinent paediatric literature regarding the management of COVID-19 disease. The papers have been reviewed by Michaela Waak and Cameron Graydon as part of the Don’t Forget the Bubbles team. This is not a systematic review, but includes relevant published online content available in the English language as of April 24th 2020. Please note some references are pre-prints, editorials or draft society documents and have not undergone peer review. This has been highlighted in the review of the article.

The review is divided into paediatric acute management, critical care management, and emerging therapies.

We will aim to add more papers as more literature becomes available. If you have suggestions for literature to add please email hello@dontforgetthebubbles.com 

Executive Summary (Updated 2nd May)

Currently, there is a paucity of data in children on optimal management because of the lower prevalence of serious cases. There are small case series’ and anecdotal reports that younger infants, medically complex and obese teenagers are at higher risk of severe disease with a possibility of genetic susceptibility. As a result of the lack of trials, only protocols for COVID-19 respiratory management and resuscitation have been published for children. The overarching principles are that best practice care should not be altered by pandemic-related concerns, other aetiologies should be looked for and broad consideration must be given to reduction in health care worker exposure.

 

Acute management

The acute management for mild and moderate respiratory illness should include home or hospital-based monitoring for clinical deterioration and for the prevention of transmission. Symptomatic and supportive care for respiratory symptoms should follow local protocols with the early consideration of a trial of prone positioning of the patient. Minimal data exists either to confirm or refute, indications or safety concerns for non-invasive respiratory support. It should be considered on an individual basis in the context of disease severity, trajectory and local resources available for protection of healthcare workers (such as negative pressure rooms, PPE) titrating to the lowest possible flow to maintain a target saturation.

Management of cutaneous, cardiac and neurological disease/complications could follow published adult evidence until paediatric published and peer-reviewed experience evolves.

There are increasing reports of cutaneous and neurological manifestations that have been hypothesised to be related to endothelial dysfunction and a hyper-coagulable state.

Additionally, reports are emerging of a constellation of findings giving a picture similar to the cardiovascular, cutaneous and gastrointestinal presentation of Kawasaki’s disease but with shock, some requiring mechanical support.  It seems to be occurring in a geographically and ethnically non-uniform distribution perhaps suggesting a genetic susceptibility. Laboratory features of raised BNP, troponin, IL-6, ferritin, d-dimers and lymphopaenia should be looked for early and consideration given to immuno-modulatory medications.  The timing of the onset of symptoms relative to positive rt-PCR and serology tests suggests an immune mediated pathophysiology – it is unsure at the moment of the exact pathophysiology but hypotheses involve direct viral effects, cytokine storm, immune complexes, abnormal T-cell or immunoglobulin responses.  The different presentations may represent a number of different immune-mediated syndromes. Treatment strategy is supportive, with consideration of immuno-modulators – some centres are treating as they would for Kawasaki’s with aspirin and IVIG.

 

Critical care management

The critical care considerations including patient and staff safety, infrastructure, patient flow, planning for PPE, and intra-and inter-hospital transfer should follow published hospital, national and international guidelines, and recommendations. Best practice care considerations for ventilated patients are of utmost importance, now more than ever, and Pediatric Acute Lung Injury Consensus Conference (PALICC) recommendations should be followed for paediatric ARDS (PARDS). This includes regular re-evaluation of the lung dynamics – which have been noted to have unexpected compliance characteristics in adults. Similar considerations apply for the neonatal critical care units where guideline summaries suggest no deviation from best-practice care especially where shared decision-making with parents is possible.

In the face of the current controversy regarding acute interventions including best practice and safety considerations surrounding resuscitation and ECLS support, national guidelines that consider international guidance statements should be followed with local best practice care support.

In the absence of sufficient data on paediatric resuscitation in positive or possible COVID-19 patients, rapid response recommendations have been formulated by the Resuscitation Council United Kingdom, American Heart Association, Advanced Paediatric Life Support, and ILCOR. ILCOR has recently published, in draft, a review of the evidence to assess which aspects of resuscitation are aerosol-generating procedures. Chest compressions, assisted ventilation, and advanced airway manoeuvres are all considered potentially aerosol-generating procedures requiring appropriate PPE, whereas defibrillation can be performed wearing droplet precautions, and most organisations suggest  covering the patient’s mouth and nose.

Paediatric extracorporeal membrane oxygenation (ECMO) for patients with COVID-19 has not been reported in the literature yet, at least two patients have been successfully weaned in Europe and form part of the ELSO registry data and increasing use in the US. It seems likely, as the pandemic progresses, that patients with indications for ECMO may also have COVID-19 infection. It is not known how this might impact upon ECMO outcomes. ELSO recommends standardisation of indications, management, data collection, and containment and consideration of ECMO support for refractory ARDS or sepsis on a case-by-case basis with consideration for capacity and resource availability.

 

Emerging Therapies

Emerging therapies include convalescent plasma, IVIG, antivirals (eg remdesivir), chloroquines, and selective cytokine blockade (eg Tocilizumab), and are currently undergoing rapid review. The pace of change and the paucity of data may mean that potential treatments and management strategies could outpace current paradigms for research and development. Novel management and data collection should be conducted in the setting of best practice trials. If relevant clinical trials are available nationally or internationally, strong consideration should be given to enrolling patients rather than prescribing off-label use.

References

PICU COVID data

First authorLast authorJournalDate of PublicationPaper link
S Balasubramanian A V RamananINDIAN PEDIATRICS 7 May 2020https://indianpediatrics.net/CONVID29.03.2020/SA-00159.pdf
Ye, Y Guyatt, G H CMAJ4 May 2020https://www.cmaj.ca/content/cmaj/early/2020/05/04/cmaj.200648.full.pdf
Al GiwaProbst, M AEB medicine3 May 2020https://www.ebmedicine.net/topics/infectious-disease/COVID-19
Health Policy TeamRCPCHRCPCH website1 May 2020https://www.rcpch.ac.uk/sites/default/files/2020-05/COVID-19-Paediatric-multisystem-%20inflammatory%20syndrome-20200501.pdf
van den Berg, JTerheggen, UESPNIC online28 Apr 2020https://espnic-online.org/Media/Files/ESPNIC-ESPR-COVID19-Transport-Consensus-recommendations-040420202
Lynch, JSultan, SIDSA guidelines website27 Apr 2020https://www.idsociety.org/practice-guideline/covid-19-guideline-infection-prevention/
Joseph, T Moslehi, M AInternational pulmonologist’s consensus group on COVID26 Apr 2020https://www.unah.edu.hn/dmsdocument/9674-consenso-internacional-de-neumologos-sobre-covid-19-version-ingles
Marini, J JGattinoni, LJAMA24 Apr 2020https://jamanetwork.com/journals/jama/fullarticle/2765302
Shen, K-LWang, X-FWorld Journal of Pediatrics24 Apr 2020https://link.springer.com/article/10.1007/s12519-020-00362-4
Cstagnoli, RLicari, AJAMA Pediatrics22 Apr 2020https://jamanetwork.com/journals/jamapediatrics/fullarticle/2765169
K ChiotisMM NakamuraJ Pediatric Infect Dis Soc22 Apr 2020https://academic.oup.com/jpids/advance-article/doi/10.1093/jpids/piaa045/5823622
Yuki, KKoutsogiannaki, SClin Immunol20 Apr 2020https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169933/
Chiotos, K.Nakamura, MJ Pediatric Infect Dis Soc18 Apr 2020https://academic.oup.com/jpids/article-pdf/doi/10.1093/jpids/piaa045/33112599/piaa045.pdf
APLS AustraliaRetrieved from the APLS Australia website14 Apr 2020https://apls.org.au/sites/default/files/uploadedfiles/APLS%20Australia%20Statement%20on%20Paediatric%20Resuscitation%20during%20the%20COVID-19%20pandemic%20v1.0.pdf
Matava, CTFiadjoe, JEAnesthesia & Analgesia13 Apr 2020https://journals.lww.com/anesthesia-analgesia/Abstract/publishahead/Pediatric_Airway_Management_in_COVID_19_patients__.95683.aspx
Matthai, J Sobhan, PIndian Pediatr. 12 Apr 2020https://indianpediatrics.net/CONVID29.03.2020/SA-00162.pdf
MatthaiSobhanInd Pediatrics12 Apr 2020https://www.ncbi.nlm.nih.gov/pubmed/32279064
Mimouni, FMendlovic, JJournal of Perinatology10 Apr 2020https://www.nature.com/articles/s41372-020-0665-6
Morray, B. H.Sathanandam, S. K.J Invasive Cardiol9 Apr 2020https://www.invasivecardiology.com/sites/invasivecardiology.com/files/articles/images/Morray%202020%20Apr%209%20AOP%20wm.pdf
MorraySathanandam J Invasive Cardiol9 Apr 2020https://www.invasivecardiology.com/articles/resource-allocation-and-decision-making-pediatric-and-congenital-cardiac-catheterization-during-novel-coronavirus-sars-cov-2-covid-19-pandemic-us-multi-institutional-perspective
BalasubramanianRamananInd Pediatrics9 Apr 2020https://www.ncbi.nlm.nih.gov/pubmed/32273490
Edelson, DTopjian, ACirculation9 Apr 2020https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463
Thampi, SOng, JPaediatr Anaesth8 Apr 2020https://onlinelibrary.wiley.com/doi/epdf/10.1111/pan.13863
Phua, JDu, BLancet Resp Med6 Apr 2020https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(20)30161-2.pdf
Ashokka, BChoolani, MAmerican Journal of Obstetrics and Gynecology3 Apr 2020https://www.ajog.org/article/S0002-9378(20)30430-0/fulltext
AshokkaChoolaniAm J Obs & Gyn3 Apr 2020https://www.ajog.org/action/showPdf?pii=S0002-9378%2820%2930430-0
Wilson, KRello, J American Thoracic Society3 Apr 2020https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/covid-19-guidance.pdf
Misra, D. PZimba, O.Clin Rheumatol 202031 Mar 2020https://link.springer.com/article/10.1007/s10067-020-05073-9
DP MisraO ZimbaClin Rheum31 Mar 2020https://link.springer.com/article/10.1007%2Fs10067-020-05073-9#author-information
Hasan, AFergie, JCureus31 Mar 2020https://www.cureus.com/articles/29784-coronavirus-disease-covid-19-and-pediatric-patients-a-review-of-epidemiology-symptomatology-laboratory-and-imaging-results-to-guide-the-development-of-a-management-algorithm
Cooper, KPerkins, GD International Liaison Committee on Resuscitation (ILCOR)30 Mar 2020https://costr.ilcor.org/document/covid-19-infection-risk-to-rescuers-from-patients-in-cardiac-arrest
Chandrasekharan, PLakshminrusimha, SAmerican Journal of Perinatology30 Mar 2020https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0040-1709688.pdf
Cook, T MHiggs, AAnaesthesia27 Mar 2020https://onlinelibrary.wiley.com/doi/full/10.1111/anae.15054
Ford, NDoherty, MJIAS26 Mar 2020https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.25489
Mimouni Mendlovic J Perinatology25 Mar 2020https://www.nature.com/articles/s41372-020-0665-6.pdf
Al Giwa, LLBDuca, AEmerg Med Pract24 Mar 2020https://www.ebmedicine.net/topics/infectious-disease/COVID-19
Kneyber, MRimsensberger, PEuropean Society for Paediatric and Neonatal Intensive Care23 Mar 2020https://scp.com.co/wp-content/uploads/2020/04/2020-ESPNIC-PEMVECC-COVID-19-practice-recommendations.pdf.pdf
Molloy, EBearer, CFPediatric Research23 Mar 2020https://www.nature.com/articles/s41390-020-0881-y_reference.pdf
Wang, YZhu, L-QWorld Journal of Pediatrics 12 Mar 2020https://link.springer.com/content/pdf/10.1007/s12519-020-00353-5.pdf
Shen, K-LYang, K-LWorld Journal of Pediatrics5 Feb 2020https://link.springer.com/content/pdf/10.1007/s12519-020-00344-6.pdf

Critical care management

Ziehr DR, Alladina J, Petri CR, et al. Respiratory Pathophysiology of Mechanically Ventilated Patients with COVID-19: A Cohort Study [published online ahead of print, 2020 Apr 29]. Am J Respir Crit Care Med. 2020;10.1164/rccm.202004-1163LE. doi:10.1164/rccm.202004-1163LE

Boston group peer reviewed publication of a retrospective case series (66 patients intubated during March 11-30). Description of the hospital recommendations included not to use high-flow nasal cannula or non-invasive ventilation, favouring volume-cycled ventilation with a target tidal volume below 6 cc/kg ideal body weight. Early prone ventilation was promoted for patients with a P/F ratio <200 and PEEP was titrated as per ARDSnet table, titration by best compliance, or oesophageal manometry. 85% of patients met the Berlin definition of ARDS. They conclude that their findings differ from earlier series describing near-normal respiratory system compliance and lack of recruitability in early presentations of COVID-19 respiratory failure. Their cohort was managed with established ARDS therapies including low tidal volume ventilation, conservative fluid administration, and prone ventilation. Minimum follow-up was 30 days, overall mortality was 16.7% and most patients were successfully extubated and discharged from the ICU.

 

Marini JJ, Gattinoni L. Management of COVID-19 Respiratory Distress. JAMA. Published online April 24, 2020. doi:10.1001/jama.2

Expert opinion paper on ARDS by two Italian authors. The concept of two phenotypes, the traditional “baby lung” classic ARDS pathophysiology versus CARDS with “type L” and high compliance and “type H” with low compliance is described. The table contains suggestions for respiratory management at different time periods (before intubation, during mechanical ventilation, after intubation and weaning phase). These hypotheses have been debated in the literature – based on findings by the Boston group, published as a cohort study by the American Thoracic Society – suggests that management should follow published ARDS management strategies and diagnostic criteria.  Discussion around the Boston cohort has included that they may be patients presenting later in their disease process.

 

Chandrasekharan P et al (April 8, 2020), Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed SARS-CoV-2 Infection., American Journal of Perinatology, https://doi.org/ 10.1055/s-0040-1709688. ISSN 0735-1631.

This peer-reviewed and published guideline summary article has been authored by international neonatologists (US and Europe).

It outlines the precautions and steps to be taken before, during, and after resuscitation of a newborn born to a COVID-19 mother. Three optional variations of current standards are proposed and involve shared decision making with parents for perinatal management, resuscitation of the newborn, disposition, nutrition, and post-discharge care. The authors highlight that availability of resources may also drive the application of these guidelines.

Key points involve:

  • Unclear risk of vertical transmission (transmission from family members/providers to neonates is possible).
  • Importance of appropriate PPE (airborne vs. droplet/contact precautions for providers to prevent transmission)
  • Parent engagement (shared decision-making: options for rooming-in, skin-to-skin contact, and breastfeeding)

This summary article highlights the key features of current recommendations including options when shared decision making is possible, the tables and diagrams add to the practical scenarios.

 

Edelson et al. Interim Guidance for Life Support for COVID-19. From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians, Originally published 9 Apr 2020 https://doi.org/10.1161/CIRCULATIONAHA.120.047463

This publication contains interim guidance on resuscitation for COVID19 suspected or positive patients including in the paediatric and neonatal setting. It is produced by the AHA in collaboration with several other American societies. General principles include the provision of best practice care balanced with reduction in provider exposure. The main considerations include donning of appropriate PPE before entering the scene and limiting personnel, prioritization of oxygenation and ventilation strategies with lower aerosolization risk (including the application of viral filters) and person-centered consideration of the appropriateness of starting and continuing resuscitation (goals of care for the individual patient).

Specific considerations are given for children and neonates. In cases of out of hospital cardiac arrest – lay rescuers of children should perform chest compressions and consider mouth to mouth ventilation if willing and able, especially if the household members have been exposed to the victim at home. If a face mask is available, it can be placed on the victim or the rescuer if bystanders are unable or unwilling to perform mouth-to-mouth. 

Neonatal resuscitations – Routine initial care, avoid suctioning of the airway. Endotracheal medications such as surfactant and epinephrine (adrenaline) are considered aerosol-generating procedures. Intravenous delivery of epinephrine via a low-lying umbilical venous catheter is the preferred route of administration during neonatal resuscitation.

The provided figures and tables complement this concise guidance statement and are well worth the read for any acute care provider.

 

Couper K et al, COVID-19 infection risk to rescuers from patients in cardiac arrest; on behalf of the International Liaison Committee on Resuscitation. International Liaison Committee on Resuscitation. 2020. “COVID-19 Infection Risk to Rescuers from Patients in Cardiac Arrest.” https://costr.ilcor.org/document/covid-19-infection-risk-to-rescuers-from-patients-in-cardiac-arrest. Draft version accessed 12th April 2020

This document contains the ILCOR Draft Treatment Recommendations in the pre-published form.

The main suggestions read:

  • We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence)
  • We suggest that in the current COVID-19 pandemic lay rescuers consider chest compressions and public access defibrillation (good practice statement).
  • We suggest that in the current COVID-19 pandemic, lay rescuers who are willing, trained and able to do so, consider providing rescue breaths to infants and children in addition to chest compressions (good practice statement).
  • We suggest that in the current COVID-19 pandemic, healthcare professionals should use personal protective equipment for aerosol-generating procedures during resuscitation (weak recommendation, very low certainty evidence).
  • We suggest it may be reasonable for healthcare providers to consider defibrillation before donning personal protective equipment for aerosol-generating procedures in situations where the provider assesses the benefits may exceed the risks (good practice statement).

 

APLS Australia,   Statement    on    Paediatric    Resuscitation    during    the    COVID-19    Pandemic, retrieved from the APLS Australia website on 14th April 2020

APLS Australia has released recommendations that are consistent with ANZCOR and ILCOR guidelines. 

While recognising the concerns of health care providers regarding the risk of transmission of coronavirus they stress the importance any delays have to outcomes. Risk to rescuers is increased (chest compressions and positive pressure ventilation have the potential to generate aerosols) but the underlying principles for CPR remain unchanged. They stress that efforts to anticipate deterioration will allow opportunity for early PPE donning in order to minimise delays.

They also recognise that healthcare systems will need to consider: availability and distribution of appropriate PPE; education of the workforce in appropriate PPE donning and disposal techniques; appropriate resources and personnel to provide on-going care for children resuscitated after cardiac arrest; paediatric resus simulation in the local environments; and for staff to become familiar with and adhere to local guidelines which describe the PPE that should be worn for aerosol generating procedures. 

 Treatment recommendations are given for three situations: 

Out-of-hospital recommendations: 

  • Health care professionals and lay rescuers who are willing, trained and able to do so, should continue to deliver rescue breaths to children in addition to chest compressions.  
  • If rescuers are untrained or unwilling to perform rescue breaths, chest compression only CPR is preferable to no CPR. 

ALS in hospital recommendations:

  • Healthcare professionals should use PPE for aerosol-generating procedures during resuscitation in children with confirmed or suspected COVID 19 infection.  
  • People in the room should be minimised consistent with appropriate care.  
  • Risk associated with aerosol-generating procedures (AGPs) should (where practical) be minimised by:  
    1. Addition of viral filters on all airway devices (BVM, SGA, ETT) where available 
    2. Preferentially allocating the most experienced clinician to manage the airway 
    3. Recognising that a cuffed endotracheal tube (ETT) is preferable to a supraglottic airway (LMA or I-Gel), which is preferable to bag-valve-mask (BVM) ventilation (optimally using a two-person technique, with an oropharyngeal airway, to minimise leak) to minimise aerosol production 
    4. Healthcare professionals should anticipate potential clinical deterioration in high risk patients and don appropriate PPE in preparation for resuscitation 

 Pre-hospital and Rapid Response Teams recommendations: 

  • Use PPE for aerosol-generating procedures during resuscitation in children with confirmed or suspected COVID 19 infection. 
  • To don appropriate PPE prior to arrival at the scene in anticipation of the need to perform aerosol generating procedures during resuscitation.  
  • For early communication with the teams to where they are transferring the patients to allow them to prepare and use appropriate PPE. 

 

Kevin C. Wilson, Sanjay H. Chotirmall, Chunxue Bai, and Jordi Rello on behalf of the International Task Force on COVID‐19.  COVID‐19: Interim Guidance on Management Pending Empirical Evidence, From an American Thoracic Society‐led International Task Force.

The American Thoracic Society convened an international group of experts to develop Consensus on Science with Treatment Recommendations (CoSTR) in the absence of high-grade evidence as of 3rd April.  These recommendations are published as an open-access document on the ATS website.

The main suggestions refer to ARDS rescue management interventions:

  • prone positioning in patients with refractory hypoxemia and COVID-19 pneumonia (i.e. acute respiratory distress syndrome [ARDS])
  • consideration for extracorporeal membrane oxygenation (ECMO) in patients who have refractory hypoxemia, COVID-19 pneumonia (i.e. ARDS), and have failed prone ventilation, and
  • to prescribe hydroxychloroquine (or chloroquine) to hospitalized patients with COVID-19 pneumonia if all of the following apply: a) shared decision-making is possible, b) data can be collected for interim comparisons of patients who received hydroxychloroquine (or chloroquine) versus those who did not, c) the illness is sufficiently severe to warrant investigational therapy, and d) the drug is not in short supply

While referencing adult patients, consideration should be given to the broader applicability of adult recommendations, particularly to our young adult patients.

 

Practice recommendations for the management of children with suspected or proven COVID-19 infections; Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) Section Respiratory Failure – European Society for Paediatric and Neonatal Intensive Care

This consensus statement issued by the European Society for Paediatric and Neonatal Intensive Care in March 2020 is published through the ESPNIC COVID-19 resource webpage.

This is a pragmatic and very useful guide for clinicians caring for COVID-19 positive children with respiratory symptoms.

Main recommendations include:

  • Monitoring respiratory failure severity by the SpO2/FiO2 ratio for noninvasive ventilation; oxygenation index for invasive ventilation.
  • The definition of paediatric ARDS remains unchanged, recommendations for non-invasive and invasive ventilation initiation and settings and PARDS management recommendations including for neuromuscular blockade, prone positioning, escalation of therapies for refractory hypoxemia and caring for the invasively ventilated child are highlighted.

Of note: These recommendations do not suggest deviation from best-practice care as per previously published PALICC guidelines. In fact, critically appraising the data coming from adult practice, before making use of these in paediatric practice is strongly recommended.

 

Jason Phua et al (April 6,2020), Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations, Lancet Respir Med 2020, https://doi.org/10.1016/S2213-2600(20)30161-2

This is a summary article published for the Asian Critical Care Clinical Trials Group. It highlights the epidemiological and clinical features of critically ill COVID-19 patients as of April 2nd, 2020 and emphasizes the evolving case fatality rate in adults of 5.2% compared to 9.6% for SARS and 34.4% for MERS.

Key recommendations include that clinicians should have a high index of suspicion, and a low threshold for diagnostic testing, for COVID-19 as clinical features are non-specific. They should cautiously evaluate unanswered clinical management questions, including the role of non-invasive ventilation, high-flow nasal cannula, corticosteroids, and various repurposed and experimental therapies.

Surge options and preparations are highlighted as important. These include optimizing infrastructure, supplies, staff protection from nosocomial transmission and the promotion of mental wellbeing. Table 3 focuses on evolving therapies and highlights the general lack of peer-reviewed published safety data.

Even though it is mainly based on adult data and authored by the Asian trials group, this article highlights important management and safety considerations for the paediatric setting.

 

Acute management

Shen KL, Yang YH, Jiang RM, et al. Updated diagnosis, treatment and prevention of COVID-19 in children: experts’ consensus statement (condensed version of the second edition) [published online ahead of print, 2020 Apr 24]. World J Pediatr. 2020;1‐8. doi:10.1007/s12519-020-00362-4

Peer reviewed and published paper summarising the chinese guidelines for management of children with COVID-19 disease authored by 30 Chinese experts from 11 national medical academic institutions. Epidemiology is summarised and case definitions clarified. Early warning signs of more severe cases are specified (increased respiratory rate, persistent high fever, lethargy, decreased blood lymphozytes, increased liver enzymes, metabolic acidosis, increased D-dimers, desaturation, extrapulmonary complications, co-infection with other viruses/bacteria). Glucocorticosteroids are recommended for 5 days for severe ARDS. Other treatments including antivirals and convalescent plasma are recommended only as part of clinical trials.

 

Lynch J, Sultan S. Infectious Diseases Society of America Guidelines on Infection Prevention in Patients with Suspected or Known COVID-19; Published by IDSA, 4/27/2020, posted online at www.idsociety.org/COVID19guidelines/ip

This guideline by an American MDT expert panel will be updated online. It contains an executive summary, background, definitions and recommendations based on a literature review and expert consensus on the use of PPE for HCP providing care for patients with suspected or known COVID-19. Recommendations on use of N95 masks and respirators, shoe covers, double vs single glove, face shields and surgical masks. The algorithm provided shows a clear process of what PPE to use in which settings and use either a surgical mask or N95 (or N99 or PAPR) respirator as part of appropriate PPE depending on the procedure related risks.

 

Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020;75(6):785‐799. doi:10.1111/anae.15054
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This peer reviewed published article by a UK anaesthetic expert group aims to provide clinicians with figures and text to be adapted locally for safe provision of airway management in patients with COVID-19 disease drawing on published literature and immediately available information from clinicians and experts. Topics covered include the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required, and the selection of equipment namely for emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest, anaesthetic care; and tracheal extubation. The overarching principle suggested is SAS – safe (for staff and patient), accurate (avoid unreliable, unfamiliar or repeated technique) and swift (timely, without rush or delay). The flowcharts, figures, photos and diagrams provided summarise and highlight the crucial principles and practical suggestions. The panel agreed on eight recommendations and provided narrative summaries of other interventions undergoing evaluations.

 

Castagnoli R, Votto M, Licari A, et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA Pediatr. Published online April 22, 2020. doi:10.1001/jamapediatrics.2020.1467

This published and peer reviewed paper from a respected Italian group is a systematic review that assesses and summarises clinical features and management of children with SARS-CoV-2 infection. They included eighteen studies with 1065 participants that reflected research performed in China, except for 1 clinical case in Singapore. Mild respiratory symptoms (fever, dry cough, and fatigue) or asymptomatic children were most commonly described. CXR or CT showed bronchial thickening and ground-glass opacities, and these findings were also reported in asymptomatic patients. No deaths were reported in children aged 0 to 9 years. Available data about therapies were limited. Antibiotics and supportive care were most commonly described, most patients did not require oxygen therapy. They conclude that many therapeutic questions in children with COVID-19 remain unanswered, so in the interim, paediatric knowledge stems from the management of other respiratory infectious diseases.

 

van den Berg J, Terheggen U. European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 infants and children, European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

This expert statement published on the ESPNIC website and endorsed by the European society of paediatric research (ESPR) describes procedures and precautions for safe retrievals of infants and children with confirmed or suspected COVID-19. Keypoints include case definitions, PPE suggestions, Airway management, respiratory support recommendations, special considerations for neonates and parents and decontamination recommendations for the transport vehicle.

The summary recommendations regarding respiratory support read:

  • “Use high-efficiency particulate air (HEPA) filters on expiratory and inspiratory hose of ventilator
  • NIV including CPAP and HFNC increases risk of aerosol spread of viral particles
  • Use any form of NIV with caution, if so, best provided by a ventilator with filters / closed circuits systems and under full PPE
  • Consider early intubation

 

The Royal College of Paedaitrics and Child Health publish guidelines on management of ” Paediatric Multisystem Inflammatory Syndrome Temporally Associated with COVID-19 (PMISTAC)

This guidance document published on the Royal College of Paediatrics and Child Health website provides the first case definition and recommendation document raising awareness to clinicians and has been developed after expert review of the cases. In rare instances children that test positive for COVID-19 can present with a multisystem inflammatory syndrome that shows features of Kawasaki disease, staphylococcal and streptococcal toxic shock syndromes, bacterial sepsis and macrophage activation syndromes. Early recognition by paediatricians and specialist referral including to critical care is essential. A clinical management summary is provided and includes health care worker protection, early management, monitoring, and general treatment principles. An MDT approach involving PICU and paediatric infectious diseases, immunology, rheumatology is suggested. Candidate antiviral therapies should only be given in the context of a clinical trial if available (e.g. RECOVERY trial) and all children should be considered for recruitment in research studies such as DIAMONDS and ISARIC-CCP. Any child being considered for antiviral therapy should be discussed at an MDT, Immunomodulatory therapy should be discussed with paediatric ID and/or clinicians with appropriate experience in their use (e.g. rheumatology, immunology, haematology) on a case by case basis and used in the context of a trial if eligible and available.

 

Ye, G Guyatt . Treatment of patients with non severe and severe coronavirus disease 2019: an evidence based guideline. CMAJ 2020.doi: 10.1503/cmaj.200648; early-released April 29, 2020

Published and peer reviewed paper from an international expert panel that included two consumers concludes:

“Given the largely very low-quality evidence regarding benefits of the treatments that the panel considered, and given the panel’s inferences regarding patient values and preferences, the panel made almost exclusively weak recommendations against use of the interventions included in this guideline. The research community should interpret the weak recommendations that this guideline offers as a call to urgently undertake rigorous RCTs of the candidate interventions.” It is designed as a “living guideline” that is updated as evidence evolves.”

In summary current recommendations read:

  • Available evidence is either indirect (from studies of influenza, severe acute respiratory syndrome and Middle East Respiratory Syndrome), from observational studies, or RCTs limited in sample size and rigour, permitting only weak recommendations and very large uncertainty.
  • The panel made only 1 weak recommendation in favour of treatment: use of corticosteroids in patients with acute respiratory distress syndrome (ARDS), based on indirect evidence.
  • The panel made weak recommendations against use of corticosteroids in patients without ARDS, against use of convalescent plasma and against several antiviral drugs that have been suggested as potential treatments for COVID-19.
  • Rigorous randomised trials are urgently needed to establish the benefits and risk of candidate interventions.

 

Giwa AL, Desai A, Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020;22(5):1‐28.

This is a second updated paper from Giwa et al. – authors in Italy and New York.  While some of the information is already out of date it gives an excellent and comprehensive summary of pathology, infection control management, evaluation, imaging and treatment options.

 

Balasubramanian et al. Coronavirus Disease (COVID-19) in Children – What We Know So Far and What We Do Not? INDIAN PEDIATRICS; APRIL 09, 2020 [E-PUB AHEAD OF PRINT]

Literature Review published in the Indian Journal of Pediatrics

Summary findings:

Pediatric COVID-19 infection usually mild or asymptomatic and with better prognosis (mortality rare)

Hypotheses of reasons for milder disease: differences in immune system function, differences in the expression/function of the cellular receptor for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) – Angiotensin converting enzyme 2 (ACE2)

COVID-19 in immunosuppressed children

No severe cases reported (may be protected by their weaker immune response), no data available on severity of COVID-19 infection in children with malnutrition, rheumatic heart disease or HIV

Children with COVID-19

Early management: supportive therapy (adequate nutrition, fluid /electrolyte management O2 supplementation, communication with parents, alleviating anxiety

Severely affected children: Respiratory management as per Pediatric Lung Injury Consensus Conference Group (PARD)

Decision to start antiviral or immunomodulatory treatment should be made carefully in consultation with experts in pediatric infectious disease and immunology and ideally as part of a trial (Hydrochloroquine only without Azitromycin, Lopinavir/Ritonavir, Tolizizumab, Anakinra)

Neonatal management (newborns of COVID-19 infected mothers):

  • Only essential personnel attending with full PPE, follow standard neonatal resuscitation measures, self-inflating mask to be used if positive pressure ventilation required,
  • newborn tested at 24 and 48 hours of life, until 2 consecutive negative tests
  • Antivirals/hydroxychloroquine/steroids or intravenous immunoglobulin (IVIG) should not be administered
  • Breastfeeding encouraged with the mother wearing a mask
  • vaccinations prior to discharge from the hospital

 

Matthai et al. for The Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition.    Coronavirus Disease (COVID-19) and the Gastrointestinal System in Children. Accessed 12 April 2020 (This is a preprint version of an article submitted for publication in Indian Pediatrics)

This is a review article pertaining to COVID and the GI system in paediatrics.

Similar to the respiratory mucosa, angiotensin converting enzyme-2 (ACE-2) receptor and transmembrane serine protease 2 (TMPRSS2) co-express in the gastrointestinal tract, which facilitates viral entry into the tissue. Less than 10% of children with infection develop diarrhea and vomiting. Prolonged rt-PCR positivity in the stool has raised the possibility of feco-oral transmission though they note that there has only been one case of active virus cultured from a stool specimen. It is unclear whether prolonged persistence of RNA in the stool is secondary to its continued positivity in bronchoalveolar sputum, even when nasopharyngeal mucosa swabs are negative.

They suggest upper GI endoscopy carries a higher risk of aerosols then lower GI endoscopy and acute upper or lower GI bleeding, esophageal obstruction, foreign body ingestion etc. may require endoscopy without delay, but should be done with full personal protection equipment including the N95 mask.

A mild rise in bilirubin and transaminases is seen in approximately 25% and more common, approximately 50% with severe disease. Consideration should be given to hypoxic and drug related liver injury (Remdesivir, Tocilizumab) aetiologies.

Available evidence is that IBD and liver transplant patients do not have an increased risk of developing Covid-19 and should stay on their immunomodulating medications. They recommend in an established COVID-19 infection, to continue calcineurin inhibitors targeting a lower trough levels and lower the dose of mycophenolate or azathioprine. Patients on high dose steroids, should have it reduced to a minimum dose based on body weight to prevent adrenal insufficiency.

Children on treatment for chronic liver diseases like Wilson disease, autoimmune hepatitis, Hepatitis B and C should continue their treatment protocols.

 

Morray BH et al. Resource Allocation and Decision Making for Pediatric and Congenital Cardiac Catheterization During the Novel Coronavirus SARS-CoV-2 (COVID-19) Pandemic: A U.S. Multi-Institutional Perspective. J Invasive Cardiol. 2020 Apr 9. pii: JIC20200409-2. [Epub ahead of print] PMID: 32269177

This article is a review of congenital cardiac catheterization practices in 56 US pediatric cardiac centers and highlighted the differences between institutions in high prevalence areas and low prevalence areas.

Noting a large decrease in activity across all centers they discuss the general approach and urgency of cases.

They classified cases in Table 3, but briefly:

1A (urgent/emergent) – haemodynamic instability

  • Pericardiocentesis; atrial septostomy for TGA; atrial septal decompression for HLHS; atrial septal decompression on ECMO; Impella (Abiomed) placement; thrombectomy for symptomatic PE with significant RV strain; coiling of AP collaterals/bronchial arteries due to hemoptysis. 1B (urgent/emergent) – to enable evaluation or discharge
  • PDA/RVOT stenting for decreased pulmonary blood flow; balloon valvuloplasty of critical or severe AS/PS; perforation of PV for PA/IVS; PDA closure in premature infants; biopsy in OHT for acute rejection; surveillance after recent OHT.

2 (semi-elective) – a delay in procedure (>30 days) could be detrimental

  • Pulmonary vein stenosis and significant RV dysfunction; heart failure and a large PDA or muscular VSD/s; increasing aortic valve/pulmonary valve gradients that already meet the threshold for intervention; venous interventions to treat occlusions/ stenoses to alleviate symptoms.

3 (elective) – can be delayed >30d

  • Secundum ASD; PDA without significant heart failure; moderate pulmonary aortic valve stenosis; pulmonary valve dysfunction awaiting pulmonary valve replacement; presurgical catheterization (pre-Fontan catheterization); routine surveillance biopsy post OHT.

There was broad consensus for delaying certain cases, and with the understanding that some cases through delay could change their relative urgency.

They recommend a local action plan should be developed for the neonate born to a positive or possible COVID mother.

They further discuss in detail the concerns in the current pandemic relating to medical resource preservation, minimizing exposure risk and resource reallocation/repurposing.

 

Thampi S et al, Special considerations for the management of COVID-19 pediatric patients in the operating room and pediatric intensive care unit in a tertiary hospital in Singapore. Paediatr Anaesth. 2020 Apr 8. doi: 10.1111/pan.13863

This article is based on a single centre experience at the National University Hospital in Singapore, a mixed adult and paediatric tertiary hospital.

General measures, as well as specific strategies in the operating rooms and paediatric intensive care unit (PICU), are presented.

PPE-related measures discussed included mask fitting and doffing/donning exercises and simulation medicine as well as powered air-purifying respirator PARP training, especially for staff who failed N95 mask fitting. With these PPE measures in place no nosocomial infections were observed. Anaesthesia considerations included a limitation on the number of accompanying adults, PPE considerations, having the most senior available operator manage the airway, the use of closed breathing systems, in-line suction and minimization of circuit disconnections as well as strict disinfection guidelines. These measures were similar in the PICU setting but also included recommendations on the use of negative pressure rooms and simulation training for emergency situations and airway management.

Limitations of this article include that it reflects accepted care in a single centre only and does not refer to the more widely accepted principle that best practice care should be provided to children during the pandemic including safe bag-mask ventilation in the event of clnical deterioration or arrest.

 

Ashokka, et al.  Care of the Pregnant Woman with COVID-19 in Labor and Delivery: Anesthesia, Emergency cesarean delivery, Differential diagnosis in the acutely ill parturient, Care of the newborn, and Protection of the healthcare personnel. 3 April 2020 (Journal Pre-proof American Journal of Obstetrics and Gynaecology) https://doi.org/10.1016/j.ajog.2020.04.005 

This is a review article with a summary of recommendations based on evidence to date.  The main recommendations:

Pertaining to staff are:

  • all healthcare staff attending to women in active labor need to don full personal protective equipment (PPE)

Pertaining care of the newborn:

  • no proven vertical transmission during pregnancy
  • possibility of acquiring the infection post-delivery

Advised against:

  • delayed cord clamping
  • skin to skin bonding between mothers and newborns

Can be considered:

  • breast feeding

Care of the unwell newborn

  • Designated NICU room with full infectious precautions

 

Mimouni et al. Mendlovic Perinatal aspects on the covid-19 pandemic: a practical resource for perinatal–neonatal specialists. Journal of Perinatology 25th Mar 2020 https://doi.org/10.1038/s41372-020-0665-6

They summarise

  • Vertical transmission from maternal infection during the third trimester probably does not occur or likely it occurs very rarely.
  • Consequences of COVID-19 infection among women during early pregnancy remain unknown.
  • We cannot conclude if pregnancy is a risk factor for more severe disease in women with COVID-19.
  • Little is known about disease severity in neonates, and from very few samples, the presence of SARS-CoV-2 has not been documented in human milk.
  • Links to websites of organizations with updated COVID-19 information are provided.
  • Infographics summarize an approach to the pregnant woman or neonate with suspected or confirmed COVID-19.

 

Al Giwa, LLB et al, Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians Publication Date March 23, 2020. Pub Med ID: 32207910

This is a peer-reviewed article dated 23rd March summarising COVID-19 data and experience from United States and Italian physicians. They provide a comprehensive review of the epidemiology, virology, pathophysiology, and management with an adult emergency department perspective.

The Italian experience in the emergency department is described – the first wave of upper airway symptoms, then patients with persistent fever and finally patients with interstitial pneumonia. Lung ultrasound was more sensitive than CXR and a useful screening tool and is discussed in some detail. Some patients presented with only gastro-intestinal symptoms and in small cohorts in California where 22% of adults and in Wuhan 40%  of children had co-infection with another virus.

Reference is made to the immunopathogenesis of COVID-19 (cytokine storm) and its implication in the rapid clinical deterioration seen. The release of inflammatory cytokines/chemokines initiates a positive feedback loop that leads to ARDS, multi-organ failure and death with histopathological features of virus-induced hemophagocytic lymphohistiocytosis. Elevated ferritin and IL-6 were associated with severe disease in adults in China.

They note the joint statement from multiple cardiology bodies highlighting there is “no clinical or scientific evidence to suggest that treatment with ACEI’s and ARB’s should be discontinued because of the COVID-19 infection.”

Even though mainly based on adult data some consideration should be given to the broader applicability in the young adult/paediatric context.

 

Hasan A, Mehmood N, Fergie J (March 31, 2020) Coronavirus Disease (COVID-19) and Pediatric Patients: A Review of Epidemiology, Symptomatology, Laboratory and Imaging Results to Guide the Development of a Management Algorithm. Cureus 12(3): e7485. doi:10.7759/cureus.7485

This is a review article from authors in the United States and has undergone peer-review.  Standard sections include epidemiology, symptomatology, imaging, labs, transmission, and a proposed management algorithm.

The algorithm recommends consideration for use of Remdesivir (which has no published in vivo data in paediatrics currently and is the subject of ongoing clinical trials) and use of procalcitonin to assess for superimposed bacterial infection (a recent systematic review by Kamat et al. did not support its use for differentiation of viral and bacterial, while a meta-analysis by Lippi suggested the higher PCT in severe COVID-19 patients might suggest bacterial infection). Serial PCTs may add to the clinical picture.

Given the limited evidence the suggestions should be taken with caution, especially in settings where clinical trials are available.

 

Matava, Clyde T, et al. On behalf of the PeDI-Collaborative Pediatric Airway Management in COVID-19 patients – Consensus Guidelines from the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society, Anesthesia & Analgesia: April 13, 2020 – Volume Publish Ahead of Print – Issue – doi: 10.1213/ANE.0000000000004872  

Given challenges to medical systems and clinicians globally due to COVID-19’s rapid spread – namely clinicians required to care for patients with a highly contagious disease without evidence-based guidelines, this consensus guideline was created. The well-established and accepted nominal group technique, a structured, multistep, facilitated, group meeting technique used to generate and prioritise responses to a specific question was virtually adapted by the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from six countries, to arrive at this published and peer reviewed guideline based on expert opinion and early data about the disease. 

They are endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society 

Overarching goals during care: 

  • minimizing aerosolized respiratory secretions  
  • minimizing the number of clinicians in contact with a patient recognizing that undiagnosed asymptomatic patients may shed the virus and infect healthcare workers 

 The main recommendations are summarised here: 

  • administering anxiolytic premedications 
  • intravenous anaesthetic inductions preferred over gas inductions, but child temperament needs to be considered 
  • tracheal intubation using video laryngoscopes and cuffed endotracheal tubes
  • use of in-line suction catheters 
  • modifying workflow to recover patients from anesthesia in the operating room 
  • Anesthesiologists should consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19 
  • Airway procedures should be done in negative pressure rooms when available 
  • Adequate time should be allowed for operating room cleaning and air filtration between surgical cases 

 Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic 

 

Emerging therapies

Immune modulation (contributed by Dr Alberto Pinzon)

ANTI-CYTOKINES 

SARS-CoV-2 induced pneumonia is characterised by hyperactivation of effector T-cells and excessive production of inflammatory cytokines, particularly IL-6 (Cheng C, Zhang XR, et al. Advances in the Research of Cytokine Storm Mechanism Induced by Coronavirus Disease 2019 and the Corresponding Immunotherapies. Zhonghua Shao Shang Za Zhi:36:e005. In Chinese). Other pro-inflammatory cytokines (i.e., IL-1, TNF and IFN-g) are likely to contribute to this cytokine storm leading to progressive immunopathology, cytopaenias, plasma leakage, increased vascular permeability and disseminated intravascular coagulation. Consequently, anti-cytokine therapy has been postulated to confer protection against severe SARS-CoV-2 disease by reversing this hyperinflammatory response (Monteleone, G, Sarzi-Puttini P.C et al. Preventing COVID-19-induced pneumonia with anti-cytokine therapy. The Lancet Rheumatology.doi:10.1016/s2665-9913(20)300092-8.)

Preliminary evidence suggest that IL-6 inhibition with Tocilizumab (anti IL-6R) can reverse the detrimental inflammatory response in severe cases of SARS-CoV-2-pneumonia. An unpublished report from China including 21 patients, 17 with severe and 4 with critical illness showed that most patients had a marked improvement in oxygen requirement and CT changes within the first week of treatment.  Interestingly, all patients survived despite the severity of their disease (Xu X et al. Effective Treatment of Severe COVID-19 Patients with Tocilizumab. Unpublished study. 2020 [https://chinaxiv.org]). Another unpublished study in 21 Italian patients with severe SARS-CoV-2-pneumonia showed that Siltuximab (anti IL-6) was able to afford improvement in 33 % of patients while also stabilising a further 43% of patients. Nonetheless, 24% of the patients worsened, suggesting that cytokine blockade appears more effective if used earlier in the disease course (Gritti G, Raimondi F et al. Use of Siltuximab in patients with COVID-19 Pneumonia Requiring Ventilatory Support. Unpublished study. 2020 [https://www.medrxiv.org])

Multiple trials evaluating anti-cytokines and immune modulators are currently underway in Europe, the US and Asia including Tocilizumab and Sarilumab (anti-IL6R), Siltuximab (anti IL-6),Anakinra (anti-IL-1), interferon beta-1, Sirolimus as well JAK/STAT inhibitors (Baricitinib/Ruxolitinib/Tofacitinib). The use of anti-cytokines should be in the context of a randomised controlled trial and thus if a clinical trial is available, consider enrolling patients rather than prescribing off-label use.

The REMAP-CAP trial (Randomised, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia) driven by the Australian and New Zealand Intensive Care Society has implemented the Pandemic Appendix to the Core protocol to respond to COVID-19. Specific domains including: no immune-modulation, interferon beta-1, and Anakinra (anti IL-1) arms have already been approved. An amendment is also planned to add Tocilizumab (anti IL-6R) and Sarilumab (anti IL-6R) as interventions.

CONVALESCENT SERUM

The successful use of convalescent serum against coronavirus infection had been previously demonstrated in patients infected by SARS-CoV (Cheng Y, Wong R, et al. Use of Convalescent Plasma Therapy in SARS Patients in Hong Kong. Eur J Clin Microbiol Infect Dis. 2005) as well as MERS-CoV. The anticipated mechanism of protection would be viral neutralisation although other mechanisms such as antibody-dependent cellular cytotoxicity and phagocytosis may be possible. In the case of COVID-19, a small study of 5 Chinese patients with severe disease in showed that convalescent serum containing neutralising antibodies improved the clinical status of all patients (Shen C, Wang Z, et al. Treatment of 5 Critically Ill Patients With COVID-19 with Convalescent Plasma. JAMA, 2020). Interestingly, a recent study of 222 Chinese patients identified risk factors for severe SARS-CoV-2-pneumonia a high neutrophil count, a low lymphocyte count and a high SARS-Cov-2-specific IgG level (Zhang B, Zhou X, et al. Immune phenotyping based on neutrophil to lymphocyte ratio and IgG levels predicts disease severity and outcome for patients with COVID-19). While these data highlight the detrimental effect of hyperinflammation with dysregulated cell counts, it also brings into focus the potential role for high non-neutralising antibody titres and thus antibody dependent enhancement (ADE) of viral entry as a contributor to disease severity. As such, convalescent serum is likely useful only in the subset of patients with poor neutralising antibody responses.

Further clinical trials of convalescent plasma are currently registered and some are underway for patients with severe or life-threatening COVID-19 disease in Europe, Latin America and the US. The FDA has in fact, approved its use under the Emergency Investigational New Drug whereby requestors must procure the convalescent serum from individual blood banks. Considerations including risk of pathogen transmission as well as adverse reactions (allergic, transfusion-associated circulatory overload (TACO), and transfusion-related acute lung injury (TRALI)) should be discussed prior to consenting patients for this treatment.  If a clinical trial is available please consider enrolling patients rather than prescribing off-label use.

INTRAVENOUS IMMUNOGLOBULIN

High dose intravenous immunoglobulin (IVIg) has long been utilised as an immune modulator in autoimmune and inflammatory diseases given its ability to modulate Fc receptors and antigen-presenting cells, inhibit the complement cascade as well as neutralise cytokines and regulate activated lymphocytes. High dose IVIg has been shown to be beneficial in SARS-CoV, MERS-CoV and influenza infections. Therefore, high dose IVIg has been proposed to modulate the severe hyperinflammatory responses associated with SARS-Cov-2. A preliminary report of three Chinese patients treated with IVIg at the early stage of clinical deterioration suggested a beneficial role despite the concomitant use of antivirals and steroids. (Cao, W, Liu X, et al. High-dose Intravenous Immunoglobulin as a Therapeutic Option for Deteriorating Patients with Coronavirus Disease 2019. Open Forum Infectious Disease. 2020).

Further trials are currently registered and underway in Europe and Asia. At present no clinical trials assessing the role of IVIg are available in Australia. If a clinical trial becomes available please consider enrolling patients rather than prescribing off-label use.

 

Yuki, K., Fujiogi, M., & Koutsogiannaki, S. (2020). COVID-19 pathophysiology: A review. Clinical immunology (Orlando, Fla.), 215, 108427. Advance online publication. 20 Apr 2020 https://doi.org/10.1016/j.clim.2020.108427

This is a recent review of the current knowledge about COVID-19 and consideration of the potential explanation of the different symptomatology between children and adults.

It has an excellent summary of the pathophysiology going into detail regarding the spike protein and subsequent activation of a fusion peptide through protease cleavage. A furin cleavage site, which has been associated with pathogenicity of viruses, is present on COVID-19. They discuss the immuno-pathogenesis especially with respect to the cellular response.

They discuss hypotheses regarding the differing clinical findings between adults and children:

  • Expression of ACE2 may differ
  • Qualitatively different response – ?immunosenescence or differing inflammatory response.

 

Ford N, Vitoria M, Rangaraj A, Norris SL, Calmy A, Doherty M. Systematic review of the efficacy and safety of antiretroviral drugs against SARS, MERS or COVID-19: initial assessment. J Int AIDS Soc. 26 March 2020. 2020;23(4):e25489. doi:10.1002/jia2.25489

This is a systematic review of the clinical outcomes of using antiretroviral drugs for the prevention and treatment of the related coronaviruses – SARS, MERS and COVID-19. Studies regarding Lopinivir/ritonavir predominated. The certainty of the evidence for the randomised trials was low. In the observational studies 3 out of 361 patients who received LPV/r died; the certainty of evidence was very low. Three studies reported a possible protective effect of LPV/r as post-exposure prophylaxis. Again, the certainty of the evidence was very low due to uncertainty due to limited sample size.

They concluded on the basis of the available evidence it is uncertain whether LPV/r and other antiretrovirals improve clinical outcomes or prevent infection among patients at high risk of acquiring COVID-19.

 

INTERNATIONAL PULMONOLOGIST’S CONSENSUS ON COVID-19; first edition Book; Editors: T Joseph and M Ashkan

This consensus statement by international authors from the US, Europe and Asia and edited by the chair of the paediatric section in World Association for Bronchology and Interventional pulmonology summarises recommendations regarding the mode of mode of transmission, epidemiology, clinical features, diagnosis, initial management, treatment options, prognostic features and prevention of patients presenting with COVID-19 disease. A summary of currently available drug treatments is summarised in table format. Critical care management is divided into respiratory management and supportive therapies. They conclude that there is presently no standardised treatment or vaccination available therefore a need for containment and prevention.

 

K Chiotis et al. Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2. J Pediatric Infect Dis Soc. 2020 Apr 22. pii: piaa045. doi: 10.1093/jpids/piaa045. [Epub ahead of print] PMID: 32318706

A panel of pediatric infectious diseases physicians and pharmacists from 18 geographically diverse North American institutions convened to develop a set of guidance statements, recognizing the lack of clinical trials and generally low quality evidence.

Their key points are supportive care is sufficient for nearly all pediatric patients with COVID-19 given the overwhelming tendency toward mild illness in children. No agent has been identified with proven efficacy against SARS-CoV-2. They suggest a decision-making framework for antiviral therapy that weighs risks and benefits based on disease severity as indicated by respiratory support needs, with consideration on a case-by-case basis of potential pediatric risk factors for disease progression. If an antiviral is used, they suggest remdesivir as the preferred agent. Hydroxychloroquine can be considered for patients who are not candidates for remdesivir or when remdesivir is not available. Antivirals should preferably be used as part of a clinical trial if available.

They addressed 4 questions:

  1. Are antiviral agents indicated in children with COVID-19?
  • Supportive care is the mainstay – if they are to be considered enroll in study and with ID support
  1. What criteria define the pediatric population in whom antiviral use may be considered?
  • They suggest antiviral agents be considered only in children with positive virologic COVID-19 testing (or with very high suspicion and no prompt testing available), and that clinical criteria, specifically respiratory support requirements, be used to define scenarios in which use of antiviral agents are considered. If patients have mild or moderate disease they should be managed without antivirals. Patients with severe disease consideration should be given to disease trajectory and comorbidities that may confer increased risk. For critical disease (new or increased need for noninvasive or invasive mechanical ventilation, or there is sepsis or multi-organ failure) can be considered on a case by case basis.
  1. Does presence of any underlying medical condition or characteristic warrant different criteria for antiviral use based on increased risk of COVID-19-related morbidity or mortality?
  • There are no definitive data to support any specific risk factor for severe COVID19 in children but they suggest consideration of immunosuppression – particularly T-cell deficiency or dysfunction, obesity, chronic cardiac or respiratory disease and diabetes.
  1. What agents are preferred if antiviral therapy is offered to children with COVID-19?
  • If an antiviral is used, the panel suggests use of remdesivir as the preferred agent.
  • If used, they stress compliance with local institutional and regulatory policies for experimental therapies, with appropriate monitoring for toxicity and the input of a pediatric ID consultant.

 

DP Misra et al. Rheumatologists’ perspective on coronavirus disease 19 (COVID-19) and potential therapeutic targets Clinical Rheumatology.  doi.org/10.1007/s10067-020-05073-9   31 Mar 2020

In the absence of high-quality evidence in this emerging disease, understanding of pathogenesis may help postulate potential therapies. Angiotensin converting enzyme 2(ACE2) appears important for viral entry into pneumocytes; dysbalance in ACE2 as caused by ACE inhibitors or ibuprofen may predispose to severe disease. Preliminary evidence suggests potential benefit with chloroquine or hydroxychloroquine. Antiviral drugs like lopinavir/ritonavir, favipiravir and remdesivir are also being explored.

Cytokine storm and secondary HLH might require heightened immunosuppressive regimens. Current international society recommendations suggest that patients with rheumatic diseases on immunosuppressive therapy should not stop glucocorticoids during COVID-19 infection, although minimum possible doses may be used. Disease-modifying drugs should be continued; cessation maybe considered during infection episodes as per standard practices. Development of a vaccine maybe the only effective long-term protection against this disease.

 

Eleanor J. Molloy et al, COVID-19 in Children and Altered Inflammatory Responses, Pediatric Research doi:10.1038/s41390-020-0881-y

This summary article highlights that severe COVID-19 infection is characterized by a massive pro-inflammatory response (cytokine storm) that can result in ARDS and multi-organ dysfunction (MODS). It suggests that patients with severe COVID-19 should be screened for HLH (increasing ferritin, decreasing platelet counts, rising ESR) to identify the subgroup of patients where anti-inflammatory treatment could improve mortality.
Therapeutic options discussed include steroids, IVIG, selective cytokine blockade (anakinra or tocilizumab), Remdesivir, hydroxychloroquine, and Janus kinase (JAK) inhibitors.

The sepsis model describes two different phases, first the cytokine storm which is followed by a period of potentially prolonged immunosuppression. The second phase is quoted as the major cause of sepsis-related fatalities.

It is suggested that anti-inflammatory therapies administered in the second phase might be deleterious and that the individualized immune response would be useful to guide therapy.

Further understanding of the differences in immune responses in different age groups is also referred to as the basis for future targeted immunotherapies.

This article provides a useful summary of the pathophysiological basis and practical implications of immunomodulatory therapies in children.

 

Kun‑Ling Shenet al, Diagnosis and treatment of 2019 novel coronavirus infection in children: a pressing issue. World Journal of Pediatrics, https://doi.org/10.1007/s12519-020-00344-6

This is an editorial from the 1st Feb discussing Interferon therapy.

Interferons are a group of low-molecular weight glycoproteins that modulate the responses of the immune system and form one of the first-line innate immune defences against viruses. There are three groups – alpha, beta, and gamma – that affect different immune responses, primarily through inducing antiviral effector proteins and activating cellular immunity to clear the virus.  There is some evidence from two Chinese studies looking at respiratory viruses showing inhibition with atomized interferon. They also reference evidence of SARS-CoV infection being inhibited by an alpha-interferon in a simian model.

 

Yan Wang, Li‑Qin Zhu Pharmaceutical care recommendations for antiviral treatments in children with coronavirus disease 2019. 2 March 2020, World Journal of Pediatrics https://doi.org/10.1007/s12519-020-00353-5

This is a viewpoint paper from two authors in China. They discuss interferon-alpha, Lopinavir/ritonavir (LPVr), ribavirin, umifenovir, and chloroquine. Suggested dosing regimens are provided in a table.

Chinese expert statements recommend IFN-alpha for children in high-risk populations who have a close history of contact with suspected infected patients or those with only upper respiratory tract symptoms in the early phase. They describe contraindications to the regime as being liver function test abnormalities, CrCl reduced below 50ml/min, mental illness, severe or unstable heart disease, aplastic anaemia, and suggest caution in infants less than 2-months of age.

Ribavarin, chloroquine, and umifenovir are discussed but no recommendations are given for use.

Umifenovir is currently only available in Russia and China.

The child with a limp

Cite this article as:
Andrew Tagg. The child with a limp, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23509

This post is based on the talk Andrew Tagg was invited to give at BadEMFest20 in Capetown. Unfortunately, world events made that a little challenging.

Humans evolved from Homo erectus to Homo sapiens around 500,000 years ago. Fossils dug up from by the Leakeys in Olduvai Gorge, Tanzania, revealed how we moved from shuffling knucklewalkers to the upright hominids we recognize today. Walking on two legs allowed us the freedom to use our hands – to communicate, to use tools, and to keep ourselves safe.

 

How do we walk?

The normal human gait is comprised of three distinct phases:

  • The contact phase – from heel strike to flat foot
  • The stance phase – from flat foot to heel off the ground
  • The swing phase – the propulsion phase as weight transfers from the toes

The swing phase normally comprises 40% of the gait cycle.

 

 

Like Sherlock Holmes or his progenitor, Joseph Bell, if you watch your patient walk you can get a lot of clues as to the potential underlying pathology before you even exchange a word with them or their parents.

Antalgic gait

This hobbling gait has a normal contact phase and normal propulsion with a decreased stance phase. In essence, the patient is trying to decrease the amount of time spent bearing weight through the hip joint itself.

Trendelenburg gait

In this gait disturbance, the hip muscles are too weak and so the unaffected side drops towards the floor. It suggests a biomechanical issue such as ass avascular necrosis, or a slipped capital femoral epiphysis.

Circumduction gait

The patient swings their leg out and around to clear the floor. This is often due to a leg-length discrepancy in the delayed diagnosis of developmental dysplasia of the hip (DDH).

Equinus gait

Toe walking, though normal up to the age of three may suggest that the child is unwilling or uncomfortable engaging their gastrocnemius muscles in walking. This can occur in many conditions.

 

The rate of presentation to the emergency department with an atraumatic limp is approximately 1.4 per 1000 in children under the age of 14. It occurs more often in boys than in girls (1.7:1) and the median age is 4.4 years. When we consider the potential causes the list is massive. In this post, we are going to concentrate on both the more common conditions and those diagnoses that we really shouldn’t miss. Whilst any part of the limb might be the cause (from the toes to the hip) this post is going to focus on causes centred around the hip joint. They account for about 60% of cases of limp. That doesn’t mean you shouldn’t look in their shoes for pebbles or look at their toes though!

Let’s break it down to some age-specific diagnoses and those that can occur at any age


Late presentation of developmental dysplasia of the hip (DDH)

It is just possible that routine screening with Ortolani’s and Barlows test might have missed a case of hip dysplasia. The limb resultant limb shortening can be hard to detect if it is bilateral but this is one time to get out the tape measure and look for a leg length discrepancy as you measure from anterior superior iliac spine (ASIS) to medial malleolus.

If you don’t have a tape measure to hand then look for a positive Galeazzi sign, suggesting a shorter hip segment on the affected side.

Original by Walt Shumway

 

Transient synovitis

This diagnosis accounts for the majority of cases of atraumatic limp and may follow an upper respiratory tract infection though the evidence for causation is poor. It is most common in young boys, aged 4 to 8 years of age and is self-limiting in nature. It’s a diagnosis of exclusion rather than anything else made easier by the well-appearing, afebrile child. It should respond to simple NSAIDs though is recurrent in 20% of cases.

Dr. Sathya Subramaniam, Pediatric EM Fellow – Kings County/SUNY Downstate and The POCUS Atlas

According to Viera and Levy, bedside sonography has a sensitivity of 90% and specificity of 100% to detect an effusion. Unfortunately, it doesn’t help with determining the cause.

Occult trauma

It’s beyond the scope of this post to talk about NAI and long bone injuries in children (especially as Nikki Abela did such a great job at DFTB18) so instead, it’s worth thinking about toddlers’ fractures. These occur due to torsional force on the tibia, accompanied by a fall, and may only be picked up as tenderness over the distal third of the tibia. That first set of x-rays performed in the emergency room may not show any obvious pathology with signs only becoming obvious after a couple of weeks. This is one of those occasions where ultrasound may be much more helpful though if clinical suspicion remains it should be treated with immobilization and close follow-up. Repeat imaging may then show the beginnings of some callus formation or a radionuclide bone scan may be needed. If they are not toddling and waddling it is not going to be a toddler’s fracture.

 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 9317

Neuromuscular

Although unlikely to present as an isolated limp, cerebrovascular events may present as hemiparesis; It’s beyond the scope of this post to go into them in more detail. Watch this space.

 

Perthes disease

This is idiopathic avascular necrosis of the growing femoral head and typically presents in boys at the younger end of the scale (4 to 8 years old). Because of this, these children are often shorter than their peers and there is a possible association with hyperactivity. The classical findings on a plain AP x-ray of the pelvis include sclerosis leading to destruction and the eventual collapse and flattening of the femoral head.  As this is a biomechanical problem, they might present with a slow onset antalgic gait with pain on internal rotation and ABduction. Around 20% of cases are bilateral.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 7980

 

Both MRI and bone scan are equally sensitive if the plain films are equivocal. Treatment may be surgical or conservative depending on the degree of bone destruction and the age of the child. Left unchecked neovascularization occurs with the destruction of the femoral head.

Though first described in 1897, it was not until 1910 that it was found to be unrelated to tuberculosis. Arthur Legg, Jacques Calvé and Georg Perthes are guilty of its eponymous name.

Transient synovitis

I think we’ve said enough about transient synovitis already.

Neuromuscular

As well as a stroke a limp might be the initial feature of an ascending paralysis in Guillain-Barré. We’ll talk about that and ADEM another time.

 

Slipped Capital Femoral Epiphysis

A slipped capital femoral epiphysis or slipped upper femoral epiphysis is more common on older, overweight boys, over the age of 10 years of age. There is often a structural weakness of the physis itself so it is more common in cases of endocrine dysregulation (such as hypothyroidism) and metabolic conditions (such as renal osteodystrophy). The proximal epiphysis displaces anteriorly and laterally relative the metaphysis. Involvement of the medial obturator nerve may mean that they present as knee pain rather than hip pain. Early fixation and we mean in less than 24 hours in unstable cases, can ward off the threat of life-long pain and deformity. Plain AP films may not be enough in the case of subtle slippage. So if you are suspicious then you should go ahead and order a lateral film as well.  A lot of other hip pathology is made easier to spot in a frog-leg lateral. Don’t do this if you are suspicious of a SCFE, you might make things much, much worse.

Look for Klein’s line. A line along the superior aspect of the femoral neck should intercept with the epiphysis. Imagine it as an ice cream slipping off the cone on a hot summer day.

Adapted from case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 2715

Case courtesy of Dr. Hani Salam, Radiopaedia.org. From the case rID: 9298

 

 

Some things need to be in our differential no matter the age of the child.

Septic arthritis

The hip is the most commonly infected joint with the haemategenous spread of organisms grown dependent on the local flora. Young children (under the age of 2), those who are immunosuppressed or asplenic are at higher risk. In Australia, for instance, the commonest organisms grown are Staphylococcus aureus and Group B Streptococcus (especially now that Haemophilus influenzae b infections have been almost wiped out by immunization). In the youngest, patients consider the weirder organisms like Kingella kingae and Salmonella (in patients with sickle cell disease).

The juvenile physis does not prevent the spread from a remote source from entering the epiphysis and so haematogenous spread (rather than direct local invasion) is often the culprit. The hip is classically held in a position of external rotation, ABduction and, flexion, perhaps in an effort to maximize the joint space and minimize the pain.

It would be great if there was a way we could differentiate the serious diagnosis of septic arthritis from something less serious, such as transient synovitis. Step forward Meninder Kocher et al. and their seminal paper.

Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. JBJS. 1999 Dec 1;81(12):1662-70.

They looked at 17 years of data for patients that presented to a single tertiary hospital with an acutely irritable hip. This amounted to 282 cases in all of which only 168 had their hip joint aspirated.  Of this 168,  only 26 had true septic arthritis as confirmed by a positive culture of joint aspirate or 50,000 WCC in the aspirate with a positive culture, 9 had a positive joint culture and negative blood cultures and 3 had only positive blood cultures.  By performing a multivariate analysis they then looked for key indicators that differentiated cases of septic arthritis from the more benign irritable hip. Four key factors cropped up. They were a history of fever, inability to bear weight, a WBC greater than 12 x 109/l and an ESR ≥ 40mm/hr. If you had none of these then the probability of having septic arthritis is 0.1%. But if you have all four it jumps to 99.8%.

Of course, this is all the primary literature that most people read but when Kocher tried to validate the study having all four markers gave the chance of having septic arthritis as 93% and when Luhmann et al. tried to externally validate the criteria it dropped to 59%. Caird et al. must have realized that not many of us use ESR any more and so appended the more common C-reactive protein (CRP). Having all 5 gave a 97.5% positive predictive value though there were only 14 cases of transient synovitis, and 5 of septic arthritis.

 


 

Osteomyelitis

An indolent course and a non-specific physical examination make this a difficult diagnosis to pick up at first glance. Around 1.5-2% of all children presenting with an atraumatic limp will have osteomyelitis.  Plain films may be unremarkable early in the course of the illness and only show periosteal changes after a week to 10 days. An MRI scan is more sensitive and if the diagnosis is still a challenge then radionuclide scanning might pinpoint the infection. The hip is one of the more common joints affected (25%) followed by the tibia/fibula (25%) then the humerus (13%). Osteomyelitis and septic arthritis can coexist as infection from the bone spreads to the joint capsule.

 

One case series suggests that 40% of cases are due to transient synovitis, chronic muscle sprain or trauma accounted for 16% and no diagnosis was made in 30%. All those diagnoses we have to learn for exams are much less common (Perthes’ disease 2%, osteomyelitis 1.5%, toddlers’ fractures 1%, and SCFE 1%). What has not been mentioned, as the incidence is incredibly low is the thing that many parents worry about – cancer.

 

Malignancy

Whilst parents may not have heard of a slipped capital femoral epiphysis or Kocher’s criteria but they have heard of cancer and so we need to address it. Primary benign tumours (unicameral bone cysts, for example, as well as malignant ones can present as bony hip pain.  Hip pain can also be a presenting feature in haematological malignancies such as acute lymphoblastic leukaemia. The most common malignant bone tumours in infants are osteogenic sarcoma and Ewing’s sarcoma. Both of these are most common in the second decade of life.

Persistent pain, coupled with constitutional symptoms such as night sweats, weight loss and night pain are highly suspicious and should prompt imaging and blood tests.

 

 

 

Selected references

Please, Just STOP LIMPING from Tim Horeczko and the PEM Playbook

Septic arthritis from PEM Morsels

 

Adamson J, Waterfield T. Fifteen-minute consultation: The limping child. Archives of Disease in Childhood-Education and Practice. 2019 Jun 29:edpract-2018.

Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. JBJS. 2006 Jun 1;88(6):1251-7.

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. The Journal of bone and joint surgery. British volume. 1999 Nov;81(6):1029-34.

Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2001 Mar 1;9(2):89-98.

Herman MJ, Martinek M. The limping child. Pediatrics in review. 2015 May;36(5):184-95.

Hill D, Whiteside J. Limp in children: Differentiating benign from dire causes. Journal of Family Practice. 2011 Apr 1;60(4):193.

Hussain M, Gholipour B, Owen N. A pictorial review of the radiological presentations of the child presenting with an acute limp in the emergency department. Clinical Radiology. 2019 Oct 1;74:e14.

Kocher MS et al. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.

Leet AI, Skaggs DL. Evaluation of the acutely limping child. American Family Physician. 2000 Feb 15;61(4):1011-8.

Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency department. Journal of Clinical Ultrasound. 2006 May;34(4):190-4.

Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. Western Journal of Emergency Medicine. 2019 Mar;20(2):331.

McCarville MB. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009;9(Special issue A):S115.

Mooney III JF, Murphy RF. Septic arthritis of the pediatric hip: update on diagnosis and treatment. Current opinion in pediatrics. 2019 Feb 1;31(1):79-85.

Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ. 2010 Aug 20;341:c4250.

Ryan DD. Differentiating Transient Synovitis of the Hip from More Urgent Conditions. Pediatric annals. 2016 Jun 15;45(6):e209-13.

Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. American family physician. 2009 Feb 1;79(3):215.

Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, Sampath JS, Bruce CE. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. The Journal of bone and joint surgery. British volume. 2011 Nov;93(11):1556-61.

Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010;55(3) :284-9

Wainwright, AM; Catterall, A (2010). “Chapter 27: Legg–Calvé–Perthes disease: Its name”. In Benson, M; Fixsen, J; MacNicol, M; Parsch, K (eds.). Children’s orthopaedics and fractures (3rd ed.). London: Springer. p. 465

An evidence summary of Paediatric COVID-19 literature

Cite this article as:
Boast A, Munro A, Goldstein H. An evidence summary of Paediatric COVID-19 literature, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24063

This post is a rapid literature review of pertinent paediatric literature regarding COVID-19 disease. We are proud to have joined forces with the UK Royal College of Paediatrics and Child Health to provide systematic search, and selected reviews of all the COVID-19 literature relevant to children and young people.

Our search and review methods have changed as the pace and utility of the published literature has evolved over time. Our process involved a formal literature search (methods can be found here), followed by identification of all papers relevant to children/young people, then reading of every article by one of our team of doctors. Initially we produced a written review of all publications, however on April 17th 2020 we moved to a more selective review process. All articles were read in full, then if high enough quality, determined by consensus and involvement of a clinical academic, a written review was also produced.

As of June 30th 2020, we have again revised our process as the urgent need for rapid evidence synthesis has lessened, and the volume of research published remains extremely high, with much of it adding little to the current body of knowledge. Our search criteria has therefore narrowed, and of the articles identified as relevant, only those felt to be of exceptional quality or impact (as determined by consensus with involvement of a clinical academic) are selected for written review.

Our team of reviewers includes Alasdair Munro, Alison Boast, Henry Goldstein, Grace Leo, Dani Hall, Daniel Yeoh, Tessa Davis, Melody Redman, Sarah Sloan, Tricia Barlow, Anne Bean, Maeve Kelleher, Victoria Dachtler, Irnthu Premadeva, Lilian Nyirongo, Esther Alderson, Sunil Bhopal, Aimee Donald and Rachel Harwood.

Here we present the top 10 papers from each category (Paediatric clinical cases, Epidemiology and transmission, and Neonates). At the top is an Executive summary followed by all New and noteworthy studies.

If you have feedback please email us at hello@dontforgetthebubbles.com

Epidemiology

Around the world, children have made up a minority of confirmed cases of COVID-19 during the first wave of the pandemic, usually contributing to between 1 – 5% of total case numbers. This almost certainly represents some undercounting of children in total case numbers as many countries have focussed on testing the most unwell. As countries have become better at shielding elderly populations and moved to community testing, the proportion of cases detected in children has increased (although predominantly in older children aged 10 – 19 years).

Countries which have produced representative population seroprevalence studies (including Switzerland, Spain and Italy) have found proportionately far fewer children have been infected than adults (young children <10 years in particular).

More detailed information has emerged into childhood severity of COVID-19. A large number of children may be asymptomatic, but the true proportion is unknown. Critical illness is very rare (~1%). In data from China, the USA and Europe, there is a “U shaped” risk gradient, with infants and older adolescents appear most likely to be hospitalised and to suffer from more severe disease. Deaths in children remain extremely rare from COVID-19, with only 4 deaths in the UK as of May 2020 in children <15 years.

Transmission

Precise details regarding paediatric transmission are still being ascertained, however important trends are emerging. Low case numbers in children suggest a more limited role than was initially feared. Contact tracing data from Asia, the USA, Europe and Israel have all demonstrated a significantly lower attack rate in children than adults, including testing of asymptomatic household contacts on both PCR and serology, indicated young children in particular are approximately half as likely as adults to acquire the infection given equivalent exposure.

The role of children in passing the disease to others is unknown, in particular given unknown numbers of asymptomatic cases. Notably, the China/WHO joint commission could not recall episodes during contact tracing where transmission occurred from a child to an adult. Studies of multiple family clusters have revealed children were unlikely to be the index case, in Guangzhou, China, Israel, the USA, Switzerland and internationally. Limited data on positive cases in schools have not demonstrated significant transmission, except within adolescent populations. Studies of younger children in schools have found low rates of transmission, but with very low case numbers. Household studies with children as index cases have so far been heavily biased by either shared exposure (children and their contacts becoming infected simultaneously) or increased exposure of caregiver to their symptomatic children post infection.

Studies of viral loads in children have generally found comparable levels of virus to adults, with no consistent or clinically relevant variation by age or symptom burden. Several studies have now shown that SARS-CoV-2 can be detected by PCR in the stool of affected children for several weeks after symptoms have resolved. Studies have confirmed there can also be live virus found in the stool of infected individuals. How much virus is present, and the extent to which faecal-oral transmission may be possible is yet to be confirmed.

Clinical features

A significant proportion of children with COVID-19 do not appear to develop any symptoms, or have subclinical symptoms, but it remains uncertain what this proportion is. The most detailed paediatric population data from China showed 13% of confirmed cases had no symptoms (cases detected by contact tracing). Considering both confirmed and suspected cases, 32% of children aged 6-10yrs were asymptomatic. Data from Italian emergency departments found 21% of SARS-CoV-2 positive children to be asymptomatic. Importantly, these studies did not follow up children to determine if they later developed symptoms, so the true proportion of asymptomatic children is unknown.

Possibly the most reliable data comes from serological screening with symptom surveys, suggesting approximately 50% of children may be asymptomatic, and only 10 – 15% will exhibit symptoms consistent with COVID-19 case definitions (cough, fever, shortness of breath). These studies are subject to recall bias.

Clinical features in symptomatic children are somewhat different to adults. Children tend to have more mild illness. The most common presenting features are cough and fever, occurring in over half of symptomatic patients. Upper respiratory tract symptoms such as rhinorrhoea and sore throat are also relatively common, occurring in 30-40% of patients. It is not uncommon for children to have diarrhoea and/or vomiting (around 10% of cases), even in some cases as their sole presenting features. Several case series of rashes resembling chill blains (often occurring on feet/toes) have been reported from Europe, contemporaneously associated with the COVID-19 outbreak but with few cases simultaneously confirmed to be infected

Blood tests also show slightly different features to adults. Lymphocytopaenia is relatively rare in children, with the majority having normal or sometimes raised lymphocyte counts. Inflammatory markers such as CRP and Procalcitonin are often raised but only very mildly. Slight elevations in liver transaminases appear to be common.

Radiographic features in children are also somewhat different to their adult counterparts. Chest X-rays are often normal, and many CT chest scans are also normal. When present abnormalities are often less severe, however a reasonable number of children have bilateral pneumonia. Changes may be found on CT even in asymptomatic children. Common features in abnormal CT scans include mild, bilateral ground glass opacities, but with less peripheral predominance than is reportedly found in adults.

There appears to be little in the way of clinical signs in children to differentiate COVID-19 from other childhood respiratory virus infections, or other benign childhood illnesses.

PIMS-TS/MIS-C

A new hyperinflammatory syndrome resembling Kawasaki shock, which appears to be a delayed immune response to COVID-19 has been described. It is known as PIMS-TS in Europe and MIS-C in the USA. Published reports from London, Italy, France and the USA in a cohort of children with evidence of past COVID-19 infection have presented with early symptom of abdominal pain, vomiting and diarrhoea, with persistent high-grade fever and commonly progression on to shock with cardiac involvement. High inflammatory markers, myocarditis, macularpapular rashes and non-suppurative conjunctivitis are common. Respiratory involvement is notably absent. Investigations are underway to ascertain a link and mechanism of disease. Most cases recover quickly, but there have been deaths reported.

Consistent with adult literature, children from a Black, Asian and Minority Ethnic (BAME) background seem to be at higher risk of severe disease from acute COVID-19 infection, and are significantly overrepresented in case reports of PIMS-TS

Newborns

A large number of cases of infants born to mothers with COVID-19 have now been reported, including several hundreds from the UK. Mothers and their babies in general appear to do well. There is a small but notable increase in the rates of preterm birth, and signals of increase in rates of foetal loss/stillborn delivery. There have been a few cases of infants delivered to mothers with COVID-19, who had elevated SARS- CoV-2 IgM. This may indicate intrauterine transmission, however swab PCR from these children has been negative and false positives with IgM tests are not uncommon. There have been case reports of newborns and very young infants testing positive including several within 12 hours of age, however they have mostly not suffered any complications of the disease and required minimal respiratory support. Evidence has been found of viral invasion into placenta, indicating possible intrauterine transmission. Vertical transmission however remains rare, occurring in approximately 2% of cases of maternal infection.

When tested, breast milk has usually been negative for SARS-CoV-2, but there have been a small number of instances where it has tested positive. It is unclear if this positive result reflects live, infectious virus, and whether the source was the mother or infants who subsequently also test positive for the virus. The vast majority of newborns have not acquired COVID-19 themselves. 

Children with co-morbidities

There is a growing body of evidence reflecting a small increased risk of children with comorbidities to be hospitalised or need intensive care from COVID-19. A pan European consortium found children with chronic lung disease, congenital heart disease, neurological disease or malignancy had 3 times higher odds of needing admission to PICU; whilst this is an increased relative risk, the absolute risk remains small.  Studies from PICU admissions in the US and Italy also found the majority have some comorbidities, most commonly respiratory, cardiac or complex neurodisability. These are groups for whom there is already a background increased risk of complications from all respiratory viruses. The rates of complications from SARS-CoV-2 infection do not appear disproportionate to those from other respiratory viruses from this early data.

Conclusion

COVID-19 appears to affect children less often, and with less severity, including frequent asymptomatic or subclinical infection. There is evidence of critical illness, but it is rare. The role of children in transmission is unclear, but consistent evidence is demonstrating a lower likelihood of acquiring infection, and lower rates of children bringing infections into households. Changes in laboratory or radiographic parameters are slightly different to adults, and changes usually mild. There is some evidence of vertical transmission to neonates which appears predominantly perinatal but evidence of intrauterine infection does exist. Evidence suggests only a small increased risk to pregnant mothers and newborns compared to other groups. Children with respiratory, cardiac and complex neurodisability appear more likely to suffer complications, however not obviously more than would be expected from infection with other respiratory viruses.

Wada, K., N. Okabe and Y. Shobugawa (2020). “Infection and transmission of COVID-19 among students and teachers in schools in Japan after the reopening in June 2020.” BMJ Paediatrics Open https://bmjpaedsopen.bmj.com/content/4/1/e000854

This article (published on 29th September 2020) reports confirmed COVID-19 cases among students and teachers in elementary schools (ages 6-12 years) and junior high schools (ages 13-15 years) in Japan from 1st June to 31st July 2020.

Background:  Elementary and junior high schools in Japan began closing on 2nd March 2020 as a result of the COVID-19 pandemic. They remained closed until the end of May 2020.  They then reopened on 1st June 2020 with infection control guidelines in place, including physical distancing, face masks and hand washing.  There were restrictions on attending school if a household member had symptoms of COVID-19 and for positive cases until non-infectious.  Where judged necessary depending on numbers of positive cases in particular schools, affected classes, year groups or schools were closed for a few days to disinfect classrooms and monitor symptoms in students and teachers.  Additionally, teachers were asked to avoid high-risk settings outside of school.  These guidelines were developed by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), which also requested all schools and governing boards of education to report cases of COVID-19 in students and teachers to local public health centres, which conducted active surveillance to identify and trace close contacts and to assess routes of transmission.  This study reports on confirmed COVID-19 cases in all elementary and junior high schools for a two month period from 1st June 2020, when schools reopened, to 31st July 2020, when the summer holidays began.  During the study period, the Japanese government reported 19,115 confirmed cases of COVID-19 in Japan.

Numbers of schools, students and teachers involved in this study:  2019 data for the schools covered in this study: 19,738 elementary schools in Japan (ages 6-12 years) with 6,368,550 students and 421,935 teachers; 10,222 junior high schools in Japan (ages 13-15 years) with 3,218,137 students and 246,825 teachers.

Cases of COVID-19 reported in schools from 1st June to 31st July 2020:  Elementary schools: 105 student cases, 29 teacher cases.  Junior high schools: 63 student cases, 10 teacher cases.  Combined: 168 student cases, 39 teacher cases.  Total 207 confirmed cases in both students and teachers in both types of school covering ages 6-15 years during this 2 month period.  There were no reported deaths in students or teachers.  [NB  Data supplied from table in article, rather than text.]

Routes of possible transmission for student cases as assessed by local public health centres:  Positive cases in elementary schools resulting from transmission in households 75/105 (71%), transmission in schools 1/105 (1%), transmission outside households or schools 9/105 (9%), returning from other countries 3/105 (3%), unknown 17/105 (16%).  Positive cases in junior high schools resulting from transmission in households 38/63 (60%), transmission in schools 6/63 (10%), transmission outside households or schools 3/63 (5%), returning from other countries 2/63 (3%), unknown 14/63 (22%).

Routes of possible transmission for teacher cases as assessed by local public health centres:  Positive cases in elementary schools resulting from transmission in households 5/29 (17%), transmission in schools 0/29, transmission outside households or schools 3/29 (10%), returning from other countries 0/29, unknown 21/29 (72%).  Positive cases in junior high schools resulting from transmission in households 1/10 (10%), transmission in schools 0/10, transmission outside households or schools 0/10, returning from other countries 0/10, unknown 9/10 (90%).

Conclusions: During this two month period after schools reopened at the beginning of June 2020 in Japan, the number of reported confirmed cases of COVID-19 in elementary and junior high schools was relatively low in both students and teachers (168 cases in students and 39 cases in teachers).  Household transmission was identified by local public health centres as the source of infection for most cases in students (71% of elementary school student cases and 60% of junior high school student cases), with only 1 student case (1%) in elementary schools and 6 student cases (10%) in junior high schools identified as transmitted in schools. The route of transmission was unknown for 16% of elementary school student cases and 22% of junior high school student cases.  However, for teacher cases in both types of school the route of transmission was unknown in the majority of cases (72% of elementary school teacher cases and 90% of junior high school teacher cases).  The authors speculate that this may be a consequence of teachers being asked to avoid high-risk behaviours such as attendance at social gatherings, which may result in unsuccessful contact tracing if there are negative consequences to disclosure of activities.  No teacher cases were identified as having been transmitted in school settings.  The authors conclude that efforts to reopen schools safely will continue in order to protect children’s rights to learn and socialise.

Freeman MC, Rapsinski GJ, Zilla ML, and Wheeler SE. Immunocompromised Seroprevalence and Course of Illness of SARS-CoV-2 in One Pediatric Quaternary Care Center. J Pediatric Infect Dis Soc. October 13th 2020, https://doi.org/10.1093/jpids/piaa123 

Study of seroprevalence in 485 immunocompromised children at a paediatric quaternary centre in Pittsburgh, USA, between March and July 2020 (median age 11.9 years, range 0.79-18.9).  Testing was done on residual serum taken for other reasons, and the authors point out that this limits the capacity to compare infection rates from their results to the entire paediatric population or to make comparisons between groups.  5 patients (1%) had SARS-CoV2-IgG antibodies (control population from same institution, 0.6%).  27.2% reported a prior febrile or respiratory symptoms.  15.7% had a nasopharyngeal swab.  2 patients had rheumatological conditions, 2 solid organ transplant, and 1 solid organ malignancy.  None required respiratory support, intensive care, or died.  Only 2 patients had a positive NPS and one of these was seronegative (though the time interval between symptoms and blood test may have allowed waning of antibody levels in this case).  In this study, all paediatric patients with exposure to SARS-CoV-2 based on the presence of IgG antibodies had a relatively minor illness in contrast to reports in immunocompromised adults who seem more likely to be admitted and to have poorer outcomes than children.

Prieto LM, Toral B, Llorente A, Coca D and Blázquez D, (2020), Cardiovascular magnetic resonance imaging in children with pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 and heart dysfunction, Clin Microbiol Infect.  https://doi.org/10.1016/j.cmi.2020.10.005

The authors (from the Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid) describe their recent experience with five patients affected by PIMS-TS from April 28 to May 11, 2020. The exact mechanisms of how SARS-CoV-2 causes this transient myocardial dysfunction in children with PIMS-TS are not well understood. Cardiovascular magnetic resonance imaging (CMRI) has become the diagnostic tool of choice for patients with evidence for acute non-ischemic myocardial injury, including myocarditis in the last decade. CMRI allows for targeting several features of myocardial injury: inflammatory hyperemia and oedema, necrosis/scar, contractile dysfunction and pericardial effusion. CMRI is also a predictor of functional and clinical recovery. They state CMRI allows for a robust assessment of the extent of injury and dysfunction in clinically acute scenarios of myocardial injury but the diagnostic value of echocardiography for myocardial injury is limited by the fact that many patients with less severe disease have a normal echocardiogram and the highly variable echocardiographic findings lack specificity.

Presenting features and investigations 

All were previously healthy children, with a median age of 7 years old of varying racial backgrounds, [interquartile range (IQR), 5-12 years]. They presented at admission with fever, tachycardia and hypotension. The median white cell count was 9100 cells/mm3 and the median lymphocyte count was 1700 cells/mm3. Other ancillary tests revealed elevated cardiac biomarkers [median troponin T was 66.6 ng/l (IQR: 3.2-75.2) and NT-proBNP of 14,407 pg/ml (IQR: 3988–16,150)], and markedly increased inflammatory biomarkers like C-reactive protein and procalcitonin [10.2 mg/dl (IQR: 9.4-26.9) and 10.5 ng/ml (IQR: 3.4-14.8), respectively]. The median ferritin was 421 μg/l (IQR: 369-639) and the median interleukin 6 was 63.5 pg/ml (IQR: 27.2-216.2). 

The echocardiography revealed mild to moderate heart dysfunction in all of the patients. All of them had a positive serology against SARS-CoV-2 (Ig anti receptor-binding domain) and met criteria for PIMS-TS according to UK, WHO and CDC definitions. Z-score for coronary artery diameters were also standardly assessed.

Treatment

Patients received IVIG, and in three cases steroids were added because of persistent fever 48 hours after IVIG administration. 

Outcome

They were all discharged home with total recovery of the heart function.

A cardiovascular magnetic resonance imaging (CMRI) was performed after discharge [median day after admission: +16, (range 9-17)]. The protocol performed included steady-state free precession cine 2D sequences (short axis, 4, 3 and 2 Chamber views); study of oedema (Inversion Recovery sequence in short axis), hyperemia and capillary leak (early gadolinium enhancement) and myocyte necrosis and fibrosis (late gadolinium enhancement). Both ventricles had normal function and no oedema or abnormalities in early and late gadolinium enhancement were observed in any cases.

Conclusions 

CMRI did not show any myocardial damage in this small series of patients with PIMS-TS. CMRI is considered a highly sensitive technique to evaluate myocardial injury. Although the number of patients in this series was small, the authors felt that heart dysfunction did not seem secondary to myocardial viral injury in these children. They put forward an alternative hypothesis that the exaggerated inflammatory response observed in these children with PIMS-TS could be the cause of the heart dysfunction. The rapid recovery of the heart function after immunomodulatory treatment and the absence of myocardial abnormalities in CMRI support this hypothesis. They conclude that further studies to further elucidate the cause of myocardial dysfunction in children with multisystem inflammatory syndrome related to COVID-19 are warranted.

C. Fenizia, M. Biasin, I. Cetin et al. Analysis of SARS CoV 2 vertical transmission during pregnancy. Nature communications. October 12th 2020, https://doi.org/10.1038/s41467-020-18933-4

This is a prospective multicentre cohort study conducted in Italy. Pregnant women who tested positive for SARS CoV 2 were recruited between March and April 2020. 31 women were included in the study and these women and their newborns were investigated for evidence of congenital infection. They analysed maternal plasma (viral RNA, IgG and IgM), vaginal swab, placenta, umbilical cord plasma (viral RNA, IgG and IgM), amniotic fluid, newborn nasopharyngeal (NP) swab and breast milk (viral RNA, IgG and IgM). According to the Shah et al classification, one newborn was confirmed to have congenital infection (case no 17) and another (case no 25) was a possible congenital infection. 


Patient No 17Patient No 25
Gestation at deliveryPreterm (34/40)Term
Mode of deliveryVaginalVaginal
Maternal illness severitySevereMild
Maternal plasma viral genomePositiveNegative
Maternal plasma antibody IgG and IgM positiveIgG and IgM positive
Placental Viral RNAPositivePositive
Vaginal Viral RNAPositiveNegative
Umbilical cord plasma viral genomePositiveNegative
Umbilical cord plasma antibodyIgG positive IgM negativeIgG and IgM positive
Newborn NP swabPositivePositive then Negative at 48hrs
Neonatal clinical conditionAsymptomatic at birthAsymptomatic at birth

Along with patient 17, patient no 4 (Severe maternal infection) was the only other maternal serum that was positive for the viral genome. IgM was positive in 32.1% of maternal serum and 3.3% (1 out of 30) umbilical cord and IgG was positive in 63.3% of maternal serum and 40.0% of umbilical cord sample. Of the 10 breastmilk sample tested,  viral RNA and IgM was positive in only case no 1 (10%). They also conducted proinflammatory 84 gene pannel analysis on placental specimens from case no 17, 25 and 31 and compared it to an uninfected control placenta. There was a generalised immune activation profile in the cases (even in case 31 who had recovered 4 weeks before delivery) compared to the control.  The hyeractivation profile was most evident in case no 17 and 25 compared to case 31. A 27 cytokine assay was carried out on maternal plasma from the 4 cases and these reflected the profiles seen at the level of the mRNA in the placenta.

This study shows that congenital infection with SARS CoV 2 may be possible. Maternal illness severity may be an influential factor in the vertical transmission as there is greater proinflammatory activation both at the placental and systemic levels in the severe manifestation of the infection. Also the only two cases in which viral genome was isolated in maternal serum had severe COVID infection As patient 17 was the only one to deliver prematurely it is also important to ask whether severe infection with SARS CoV2 triggers premature labour. However, patient 25 had a mild infection but their umbilical cord bood was IgM positive and therefore confer the possibility of vertical transmission. The study is too small and therefore further research is needed to draw conclusions.

Kalamdani P, Kalathingal Y, Manerkar S, Mondkar J. Clinical Profile of SARS-CoV-2 Infected Neonates From a Tertiary Government Hospital in Mumbai, India, https://www.indianpediatrics.net/epub102020/RP-00250.pdf 

This is a retrospective case record review of infants with SARS-CoV-2 infection, born in hospital to infected mothers in Mumbai, India between 1 April 2020 to 31 May 2020

Of 1229 women admitted to the hospital in labour during the study period, 185 (15.05%) tested positive for SARS-CoV-2 infection, as ascertained by real time reverse transcriptase-polymerase chain reaction (RT-PCR) of nasopharyngeal swabs. Three (1.7%) mothers had fever and two of these three also had mild breathlessness.

The infants of these infected mothers were then tested and 12 (6.48%) were found to be positive for SARS-CoV-2 infection – 50% were tested at 48 hours, 25% at 72 hours

The median gestational age of the infected group was 38 weeks and the ratio of males to females was 2:1. No infected neonate had respiratory symptoms, lethargy or neurological symptoms. Three had fever and two had feeding difficulty. None required NICU admission and all remained with their mothers in the postnatal wards. All were breastfed. All infants in this group remained healthy at 2 months of age as ascertained by telephone follow-up.

Liver function tests were carried out in 9 infected infants and the authors state that “marked elevation of LDH levels and mild transaminitis were observed”. The actual results in the accompanying Table are: mean AST 75 IU/L, mean ALT 29 IU/L and mean LDH 1462 IU/L.

The authors conclude that SARS-COV-2 infection in neonates is mainly mild or asymptomatic and that infected neonates can be successfully roomed-in with their mothers and be breastfed.  

Knight, K. Bunch, N. Vousden et al. Characteristics and outcomes of pregnant women hospitalised with confirmed SARS-CoV 2 infection in the UK: A national cohort study using UK obstetric surveillance system. Nuffield Department of Population Health, UKOSS Publications 11th May 2020, https://doi.org/10.1101/2020.05.08.20089268

As a pre print this study should be interpreted with caution until it has undergone peer review.

This is a prospective observational national cohort study carried out across all 194 consultant-led maternity units in the UK. It captured data from women admitted to hospital with confirmed SARS CoV 2 between 01/03/20 and 14/04/20, with tests having been carried out only if the woman was symptomatic. 427 women were studied and compared to a historical control sample of 694 women admitted between 01/11/17 – 31/10/18 (a historical sample was chosen to avoid confounding by including asymptomatic or minimally symptomatic carriers of COVID). The total number of maternities in the study period was 86293 and therefore the incidence of admission the SARS CoV 2 confirmed women was 4.9 per 1000 maternities. The median gestation at admission was 34 weeks (IQR 29-38 weeks), with 81% of admissions in the 3rd trimester. The results showed that there was a statistically significant risk of admission with SARS CoV 2 patients who had the following factors:

From a Black and Minority Ethnicity group: adjusted OR 4.49 (3.37-6.00). Even after sensitivity analysis which excluded women from London, West Midlands and North West England which had high rates of general infection OR 3.67 (2.55-5.28)

Overweight: adjusted OR 1.91 (1.37-2.68)

Obese: adjusted OR 2.20 (1.56-3.10)

Pre-existing medical condition (asthma, hypertension, cardiac disease or diabetes): adjusted OR 1.52 (1.12-2.06)

Maternal age ≥ 35: adjusted OR 1.35 (1.01-1.81)

Being a current smoker reduced the risk of admission, with adjusted OR 0.3 (0.17-0.51).

The odds ratio for each significant factor outlined above was adjusted for the other significant factors which became confounding variables. There were 40 admission to level 3 critical care with 4 requiring ECMO. There were 5 maternal deaths recorded, 3 of whom had been admitted to critical care. SARS CoV 2 associated maternal mortality was 5.6 (1.3-13.1) per 100,000. Only 9 women were treated with antivirals (oseltamivir, lopinavir/ritonavir and/or remdesivir). 61 women were given corticosteroids for the maturation of fetal lung.

247 women in this cohort gave birth (singleton/multip proportion not stated) to a live infant (n=243) or had a pregnancy loss (n=4). 59% of women gave birth via c-section with 20% under general anaesthetic compared to 29% of the control group with 7% of women delivering under GA. There were 63 (26%) preterm births (<37 weeks) and 29 of these were documented as being secondary to COVID 19 infection; the other reasons stated were iatrogenic, fetal compromise and other obstetric conditions. This is compared to 8.9% of births in the control group being born preterm. There were 5 neonatal deaths, including 3 stillbirth; in two of the cases of stillbirths, it is unclear whether COVID 19 infection contributed to death. The rate of pregnancy loss, still birth, livebirth and neonatal death was not statistically different between the groups. The NICU admission rate was 26% (majority for prematurity) and 5% in the cohort and comparison groups, respectively. 12 infants tested positive for SARS CoV 2, with 6 being within the first 12 hours of life (early). 1 in the early positive and 5 in the later positive groups were admitted to NICU.

This is a national study reporting on the largest cohort of SARS CoV 2 positive pregnant women admitted to hospitals with symptoms. There is likely to be an underestimation of the true effect size presented in this report as analysis was carried out in only those patient in whom data was returned and not on the entire cohort of admissions in the specified time period.  The results convincingly show important risk factors (maternal age, black and minority ethnicity, BMI, and pre-existing medical condition) for admission and thus confers the severe of infection in these risk groups. The black and minority ethnicity risk factor, which existed even after the sensitivity analysis, requires urgent further analysis and study as it was the biggest risk factor and one which has not been demonstrated to be the case in other coronavirus strains. The supposed protective factor of current smoker status is not explained in this report but could reflect lower current prevalence of smoking in pregnancy in general compared to the prevalence at the time of the historical sample. The report also highlights that most of the admission with SARS CoV 2 was in the second and third trimester thus providing weight for the precautions currently being taken in this group of women. However, they also correctly identify that there may be a sampling bias as those in the first trimester may be being admitted to hospital via routes other than the maternity services. There was a higher rate of preterm deliveries (statistical significance unknown) which is difficult to interpret but raises questions as to what extent the maternal infection may cause fetal compromise triggering preterm birth.

2% of babies tested positive for SARS CoV 2 suggesting a risk of vertical transmission, especially since 3 of the positive cases were pre-labour, c-section delivered babies. However, the IgG or IgM status of the infants is unknown and there were no placental, umbilical cord, etc samples taken/reported. The discussion states that mothers and infants were kept together with infection control measures (surgical face masks) and the low rates of neonatal infection supports continuation of this practice. However, 6 of the 12 infants testing positive for SARS CoV2 required neonatal unit admission, majority of whom were classed as late infections as they tested positive after 12 hours of life. There is no information provided on the reason for these admissions and what support and/or treatment was required during this time. It is important to point out that the report does not specially say that all other infants born to this cohort of mothers were tested for SARS CoV 2 and found to be negative. Further questions are raised in the two cases of stillbirth which may have been caused by COVID 19. There is also no clarification on the characteristics of the cases of neonatal death (e.g. were they preterm, was mother critically ill in ITU, etc) which would have added greatly to the analysis of this report.

Although this study does not provide enough detail to draw firm conclusions, it provides an important basis for further avenues where research is needed.

Zeng L, Xia S, Yuan W et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. Published online March 26, 2020. doi:10.1001/jamapediatrics.2020.0878

This is a cohort study following 33 neonates born to COVID-19 positive mothers, recruited Wuhan Children’s Hospital, Hubei Province, China, between January 2020 and February 2020. The authors describe three cases of early-onset neonatal COVID-19, which they suggest implies vertical transmission. However, amniotic fluid, cord blood and maternal breast milk of the mothers of all 3 positive neonates were negative for SARS-CoV-2, therefore it is unclear whether the infection was transmitted vertically or environmentally.

Three of the 33 neonates tested positive for COVID-19 on day 2 of life (positive nasopharyngeal or anal swabs). All 3 were born by caesarean section, two at term and the third at 31+2 for premature rupture of membranes and foetal distress.

Clinical features: The two term COVID-19 positive neonates had fever, although the authors don’t define what temperature they consider fever. These two neonates were also lethargic, but neither had respiratory distress. Neonate 3 was the most unwell, although this may be due to prematurity, poor condition at birth and sepsis rather than COVID-19. He was born at 31+2, required resuscitation at birth and had poor Apgars of 3, 4 and 5 at 1, 5 and 10 minutes, requiring non-invasive ventilation for respiratory distress. His blood cultures were positive for Enterobacter agglomerates.

Bloods: Neonate 1 (fever and lethargy) had normal bloods except raised procalcitonin (0.09 microgram/L). Neonate 2 (fever, lethargy and vomiting) had a leucocytosis, lymphocytopenia and elevated CK. Neonate 3 (premature with sepsis) had leucocytosis, thrombocytopenia and coagulopathy with prolonged PT (21 sec) and APTT (81.9 sec).

Radiology: All 3 had radiological evidence of pneumonia on CXR.

The authors state that because strict infection control and infection prevention procedures were implemented during delivery, SARS-CoV-2 isolated from their upper respiratory tracts or anuses was therefore maternal in origin. However, although it is stated in the illustration that one neonate was immediately quarantined after birth, it’s not clear whether this was the case for the other two babies. Plus, the negative amniotic fluid and cord blood does raise the question as to whether these neonates were truly infected in utero or not.

Yu, Nan et al Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study, The Lancet Infectious Diseases, Volume 0, Issue 0, Published:March 24, 2020 DOI:https://doi.org/10.1016/S1473-3099(20)30176-6

This is a retrospective study of 7 pregnant mothers infected with COVID-19 between Jan 1st and Feb 8th at Tongji Hospital in Wuhan, China. They were all at term (range 37/40 – 41+2/40). The mothers were all symptomatic, mainly with fever, cough, shortness of breath and diarrhoea. They all delivered via emergency caesarian section. All mothers did well.

The babies were all born with normal apgars. 4 babies were discharged home and not tested for SARS-CoV-2 and never developed symptoms (including at 28d follow up phone call. 3 children were tested, of which one was positive at age 36hrs (reported in separate study, Wang et.al Clinical infectious Diseases, but did well with no fever or cough and mild shortness of breath). The other 2 tested negative and were later discharged without complication.

Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020; 395 :809–15. doi:10.1016/S0140-6736(20)30360-3

This retrospective case series looks at 9 pregnant women who were positive for COVID19 in Wuhan University Hospital between Jan 20th and Jan 31st. They all underwent a caesarean section (between 36 and 39+4 gestation). All newborn babies were well with good APGARS and, importantly, tests from 6 (3 not tested) patients were negative for SARS-CoV-2 in all amniotic fluid, cord blood, neonatal throat swabs, and breastmilk samples. There was no evidence of vertical transmission.

Dong L, Tian J, Songming H et al. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA. Published online March 26, 2020. doi:10.1001/jama.2020.4621

This is a case report that would suggest that vertical transmission of COVID-19 can occur. A 34+2 primiparous woman was diagnosed with COVID-19 (she was symptomatic with fever and respiratory difficulty and had classic CT chest findings and a positive nasopharyngeal swab for SARS-CoV-2). She was treated with antiviral medications, antibiotics and corticosteroids.

Her female infant was delivered by caesarean section 4 weeks after the onset of her mother’s symptoms in good condition with Apgars of 9 and 10. Although the infant’s nasopharyngeal swabs were negative, her IgM antibodies against SARS-CoV-2 were raised at 2 hours post delivery and cytokine levels were elevated. The risk of environmental infection was minimised: the caesarean was performed in a negative pressure room, the mother wore an N95 mask and did not hold her infant and the infant was immediately isolated in NICU. Maternal vaginal secretions were negative for SARS-CoV-2, which would also suggest the infection did not happen at birth. As IgM antibodies do not cross the placenta, the infant’s elevated IgM antibody levels suggest that she was infected in utero. Moreover, IgM antibodies usually do not appear until 3 to 7 days after infection. The infant also had raised IgG antibodies, but IgG is transferred placentally so this may reflect maternal or infant infection. The mother’s breast milk was negative for SARS-CoV-2 1 week following delivery.

Zeng H, Xu C, Fan J, et al. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA. Published online March 26, 2020. doi:10.1001/jama.2020.4861

This report outlines the course of 6 mothers who were symptomatic for COVID-19 in their last trimester, and gave birth to 6 liveborn infants. This study is notable for antibody testing of both mothers and infants. The accuracy of the antibody tests are suspiciously high given current struggles to produce adequate tests around the world, and should be treated with a high degree of caution.

All 6 infants were born in good condition, and all tested negative for SARS-CoV-2 viral throat swabs and blood PCR. Unsurprisingly all infants had elevated IgG or SARS-CoV-2 (as this crosses the placenta), but notably 2 infants had raised IgM (39.9AU/ml and 16.25AU/ml). This raises the possibility of intrauterine infection, similar to another case of an infant with raised IgM (Dong et al JAMA). Issues with cross reactivity of IgM are well described, and so whilst full validation of these tests is awaited internationally, this should be treated with caution.

Liu, Yangli et al. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy.Journal of Infection, Volume 0, Issue 0 https://doi.org/10.1016/j.jinf.2020.02.028

This is a small case series of 13 pregnant women with confirmed SARS-CoV-2 infection between December 8 2019 and February 25 2020, in China. Two women were <28 weeks at presentation, the remainder were in the third trimester. One infant was stillborn, the 12 remaining infants (92%) were well at birth with no complications. None were positive for SARS-CoV2 or had ‘serological evidence’ of vertical transmission. The method of testing neonates was not clearly defined. The stillborn neonate had a mother who was severely unwell on Extracorporeal Membrane Oxygenation (ECMO) at the time of delivery.

Five of the 10 patients (50%) were delivered by emergency cesarean section due to pregnancy complications including fetal distress (30%), premature rupture of the membrane (10%) and stillbirth (10%). Interestingly, six patients (46%) had preterm labour between 32- 36 weeks of gestation.

Han, M. S., M. W. Seong, E. Y. Heo, J. H. Park, N. Kim, S. Shin, S. I. Cho, S. S. Park and E. H. Choi (2020). “Sequential analysis of viral load in a neonate and her mother infected with SARS-CoV-2.” Clin Infect Dis. https://doi.org/10.1093/cid/ciaa447

This is a case report of a 27 day-old female neonate with confirmed SARS-CoV-2 infection. Over the course of a short and reasonably mild illness, samples were tested from the nasopharynx, oropharynx, plasma, urine, stool and saliva. SARS-CoV-2 RNA was detected in all samples. Early in the infection, viral load was highest in the nasopharynx and oropharynx, decreasing to undetectable at day 17. Viral load in stool, however, remained high throughout, despite cessation of gastrointestinal symptoms. This was in contrast to the mother’s stool sample in which viral load was undetectable earlier.

Groß, C. Conzelmann, J. A. Müller, S. Stenger, K. Steinhart, F. Kirchhoff and J. Münch. Detection of SARS-CoV-2 in human breastmilk. Lancet, May 21st 2020, https://doi.org/10.1016/S0140-6736(20)31181-8

This report is presented as a letter.

The study primarily relates to the SARS­CoV­2 content of the breast milk of two “nursing mothers” who shared a room postnatally, with their babies, and who developed swab-positive mild Covid-19 infection after birth – three days and six days respectively. The gestation and birthweights of the babies are not reported but they seem to have been full term, well at birth and initially well for the first few days following delivery.

The babies developed abnormal respiratory signs, one with jaundice, at 8 days and 11 days respectively, both becoming swab positive for SARS­CoV­2 at about the same ages and both being admitted to a Neonatal Unit. One infant, who also tested positive for RSV, subsequently required mechanical ventilation. It is stated that one infant recovered but the outcome for the ventilated infant is not given.

The patient identification and recruitment processes are not described.

Breast milk was collected, after feeds and after nipple disinfection, from each mother starting at eight days and four days respectively after development of Covid-19 symptoms. Samples were collected on postnatal days 12-15 for the first mother and 10, 12, 13, 14 and 25 for the second. Testing for SARS­CoV­2 RNA was performed using RT­qPCR.  Information on the method of nipple disinfection is not provided.

A separate laboratory-based study investigated the effect of breast milk on viral recovery rates by “spiking” breast milk with serial dilutions of a SARS­CoV­2 stock.

The main findings of potential importance are:

  1. The breast milk of one of the mothers tested positive for SARS­CoV­2 RNA at 10-13 days after birth. Testing of breast milk from the other mother was negative.
  2. Quantification using Ct values corresponded to 1∙32 × 10⁵ copies per mL in whole milk and 9∙48 × 10⁴ copies per mL in skimmed milk.
  3. An 89∙2% reduction in recovery rate in whole milk and 51∙5% in skimmed milk, suggesting that the actual viral loads in whole milk of the mother could be even higher than detected.

This study provides the first report of the detection of viral RNA in human breast milk collected from a mother who had clinical signs of Covid-19 confirmed by PCR testing of swabs. This does not provide evidence that the RNA was indicative of infectious virus or that transmission of the virus to the baby occurred via breastmilk. Further studies will be necessary to attempt to culture virus from breast milk and assess risk of transmission, which to date has seemed low.

Li, M., L. Chen, J. Zhang, C. Xiong and X. Li (2020). “The SARS-CoV-2 receptor ACE2 expression of maternal-fetal interface and fetal organs by single-cell transcriptome study.” PLoS One 15(4): e0230295. https://doi.org/10.1371/journal.pone.0230295

The study explores the presence of Angiotensin-converting enzyme 2 (ACE2) within the placenta and the developing baby. It demonstrates significant expression of RNA coding the for ACE2 protein at several points of the maternal-foetal interface, as well as variable expression in a number of foetal organs. This theoretically provides a potential route for vertical transmission, placental dysfunction and pregnancy complications. The authors call for further clinical analysis to establish this potential.

Swann Olivia V, Holden Karl A, Turtle Lance, Pollock Louisa, Fairfield Cameron J, Drake Thomas M et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ. August 27th 2020, https://doi.org/10.1136/bmj.m3249

This large prospective observational study from 260 hospitals in the UK examines the clinical characteristics of children (<19yo) hospitalised with laboratory confirmed SARS-CoV-2 infection between 17th January and 3rd July 2020; as part of the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) WHO Clinical Characterisation Protocol UK cohort. The main outcome measures were admission to critical care, in-hospital mortality and MIS-C.

Results; A total of 651 children admitted to 138 hospitals were included; median age was 4.6 (IQR 0.3-13.7); 35% were <12 months of age. Of patients with recorded ethnicity 57% were white, 12% south asian and 10% black. 56% were male and 42% had identified co-morbidities. 

Symptoms; The most common symptoms were fever (70%), cough (35%) nausea / vomiting (32%) and dyspnoea (30%). Three distinct clusters of symptoms were identified: – a discreet respiratory illness – cough, fever, dyspnoea, coryza and wheeze – a mucocutaneous enteric illness – headache, myalgia, sore throat, vomiting, abdominal pain, diarrhoea, fatigue, rash, lymphadenopathy and conjunctivitis – a rarer neurological illness – seizures and confusion

Critical care and mortality; Critical care admission occurred in 18% (116/632); 8% received inotropic support; 9% received non-invasive and invasive ventilation respectively. Children of black ethnicity had higher odds of critical care admission (OR 2.82). Infants <1mo (OR 3.21, 95% CI 1.36-7.66) and children 10-14 yo (OR 3.23, 95% CI 1.55-6.99) were also more likely to be admitted to critical care. Co-morbidities including prematurity, respiratory and cardiac co-morbidities and obesity were more common in those with critical care admission compared with those receiving ward care. Six (1%) of patients died in hospital, all had serious comorbidities; 89% of children had been discharged alive and 10% remained in hospital at the time of reporting.

MIS-C; Based on the preliminary WHO case definition, 11% (52/456) of admitted children fulfilled diagnostic criteria for MIS-C. Children with MIS-C were older than those without (median 10.7 yo vs 1.6 yo) and were more likely to be of non-white ethnicity (64% vs 42%); obesity was also more common amongst those with MIS-C (10% vs 2%). Children with MIS-C were more likely to require critical care admission (73% vs 15%), receive inotropes (51%), invasive (27%) and non-invasive (35%) ventilation. There were no deaths due to MIS-C.

Of children with MIS-C differences were noted between those who were SARS-CoV-2 PCR positive (acute phase of infection – 56%) and those who were antibody positive (post-acute phase of infection – 44%). Antibody positive MIS-C patients were more likely to be of non-white ethnicity (90% vs 45%), less likely to be obese (0% vs 19%), and more likely to have conjunctivitis (71% vs 16%) and abdominal pain (95% vs 44%) compared to those who were PCR positive. Dyspnoea was more common in PCR positive patients (52% vs 14%). Cardiac complications were also more common in the antibody positive group (75% vs 35%).

Conclusion; The findings of this large prospective study are consistent with previous studies indicating that children represent a small proportion of hospitalised cases of COVID-19 (0.9% here), that outcomes in children are generally favourable and that death due to COVID-19 in children is rare. Similar to previous studies, fever and cough were the most common symptoms, although gastrointestinal symptoms (35%) were more common in this cohort; the identification of a mucocutaneous-enteric symptom cluster with overlap with WHO MIS-C criteria is a novel finding here. Children of black ethnicity were over-represented in overall cases, as well as amongst children admitted to critical care units, consistent with adult data from the UK. Similarly, obesity was associated with increased risk of critical care admission. 

The association of MIS-C with older age and non-white ethnicity are consistent with previous studies. In addition to current WHO criteria, fatigue, headache, myalgia, sore throat and low platelet count were all associated with MIS-C.  The demographic and clinical differences identified between MIS-C patients who were antibody positive compared with those who were PCR positive suggest a spectrum of clinical presentation that varies according to phase of infection and immune response.

Götzinger, F., B. Santiago-García, A. Noguera-Julián, et al.  “COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study.” Lancet Child Adolesc Health. 

This European multicentre cohort study recruited centres from the Paediatric Tuberculosis Network European Trials Groups, to look at 582 cases of paediatric (<18 years old) SARS-CoV-2 infection in 21 countries with 77 healthcare centres. Centres from five additional countries reported no SARS-CoV-2 cases at the time of the study. The breakdown of centres included 454 (78%) tertiary, 54 (9%) secondary and 74 (13%) primary healthcare providers.

Cases were collected retrospectively from identified cases prior to 1st April and prospectively between 1-24th April. The diagnosis was made based on RT-PCR of SARS-CoV-2 alone. The age group of the population was young, with a median age of 5 (IQR 0.5-12) and 230 (40%) under 2 years of age. Just over half were male (n=311, 53%).

Index case data was included from the history, with parents being the suspected case for 324 patients (56%) and siblings accounting for 24 cases (4%). However, a large number of cases (n=234, 40%) were either from someone outside of the immediate family or of unknown transmission.

The most common symptoms were fever (n=379, 65%) and respiratory symptoms (n=313, 54% URTI and n=143, 25% LRTI). 128 (2%) had gastrointestinal (GI) symptoms and 40 (7%) had GI symptoms without respiratory symptoms. Asymptomatic patients accounted for 16% of all cases (92). There was confirmed viral co-infection in 5% (n=29) of patients. The study did not capture laboratory values. A chest x-ray was performed in 34% (n=198) of patients. Almost half of the x-rays showed findings consistent with pneumonia and ten (5%) of ARDS.

Of the patients included in the study, a quarter (145) had pre-existing medical conditions. Twenty-nine patients had pre-existing respiratory conditions (asthma accounting for 16) and malignancy was known in 27 patients. The study collected data on antiviral treatments administered however numbers were small and depended on local practice.


Across the cohort 363 patients (62%) required hospital admission, 48 (8%) required ICU admission. Factors increasing risk of ICU admission (n=48) were found to be age <1 month (n=7/48, 14.6%) the presence of any pre-existing medical condition (n=25/48 52%) and presence of lower respiratory tract infection signs at time of presentation (n=35/48, 73%). Mechanical ventilation was required for 25 patients (4%) and ECMO was needed in one patient. Data on treatments given included antivirals: hydroxychloroquine (n=40, 7%), remdesivir (n=17, 3%), lopinavir-ritonavir (n=6, 1%) and oseltamivir (n=3, 1%). Other immunomodulators used were corticosteroids in 22 (4%), IvIG in 7 (1%), tocilizumab (n=4, 1%), anakinra (n=3, 1%) and siltuximab (n=1).

There were 4 deaths (0.69%), all of which were in children older than 10 years of age. Of the four deaths, one was an out of hospital cardiac arrest and two had pre-existing medical conditions; one patient had a stem cell transplant 15 months prior and another patient was managed palliatively due to their pre-existing illness. By the end of the study period, 553 patients had made a full recovery and 25 patients had ongoing symptoms.

This is one of the first multi-national European studies of SARS-CoV-2 in children. Common symptoms included respiratory and fever but gastrointestinal symptoms were present in over one-fifth of cases. Although eight percent of children required ICU admission, the case fatality rate was low at 0.69%. Children at greater risk of intensive care admission had pre-existing medical conditions, were less than 1 month old or presented with lower respiratory tract symptoms. Asymptomatic infection occurred in 16% of cases. Given that at the time of the study, there were varying practices for screening criteria, it is likely that the true proportion of asymptomatic patients is higher (and true case fatality rate lower)

Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. N Engl J Med 2020;:NEJMc2005073. doi:10.1056/NEJMc2005073

This retrospective study examines the clinical characteristics of children with confirmed COVID-19 diagnosed at Wuhan Children’s hospital. There were 1391 children tested between Jan 28th and Feb 26th 2020 due to confirmed contact with a case of COVID-19. Of these, 171 were confirmed to have SARSCoV-2.  The median age was 6.7yrs, and there was a relatively even spread amongst age groups. Children were predominantly male (104/171, 60.8%).

Clinical features: 83/171 had cough, 79/171 had pharyngeal inflammation (sore throat), 71/171 had fever. 15/171 had diarrhoea and 13/171 had rhinorrhoea. 49/171 were tachypnoeic on admission and 72/171 were tachycardia. Only 4/171 had Oxygen saturations <92% during hospitalization. 0/31 infants <1yr were asymptomatic in this cohort, with rates of asymptomatic infection increasing with age. There were higher rates of pneumonia in infants (25/6), but their definition is unclear. We also have no information regarding co-infection with other viruses or bacteria.

Radiology: Not delineated into CXR or CT, but descriptions sound like CT findings. The most common was bilateral ground-glass opacity (56/171) followed by unilateral patchy shadowing (32/171) and bilateral patchy shadowing (21/171). There were several children with radiographic pneumonia who were asymptomatic.

Bloods: The supplementary appendix contains lab results. Only 6/171 patients had lymphopaenia, the vast majority were in normal range (Med 2.9×109/L, IQR 2.2 – 4.4). CRP was elevated (>10mg/L) in 33/171 (Med 4, IQR 1.3 – 8) of which 27/33 had pneumonia.

Outcomes: 3 patients required ITU admission and intubation. All 3 had comorbidities, including hydronephrosis, leukaemia, and intussusception. The child with intussusception suffered multiorgan failure and died after 4 weeks. The cause of death is not clear from the report. As of writing 149 patients had been discharged with 21 stable in the general wards.

Parri N, Lenge M, Buonsenso D; Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group. Children with Covid-19 in Pediatric Emergency Departments in Italy [published online ahead of print, 2020 May 1]. N Engl J Med. doi:10.1056/NEJMc2007617

This report covered confirmed COVID-19 infections in children under 18 years of age who presented to a research collaboration of 17 paediatric emergency departments in Italy between March 3rd and March 27th. The median age was 3.3 years and 57/100 were male. Children under 1 year were overrepresented (40%) followed by children >10yrs (24%).

Helpfully, the authors categorize their patients according to criteria from Dong et. al (see review in theEpidemiology top 10): Asymptomatic 21%, Mild 58%, Moderate 19%, Severe 1%, and Critical 1%. Only 12% of patients appeared ill on assessment. Interestingly only 4% of patients had oxygen saturations <94%. Only 38% of children needed admission for the severity of illness. There were no deaths. The supplementary appendix includes a huge amount of detailed analysis of the cases, which are summarised below

Clinical features: Fever 54%, Cough 44%, Feeding difficulty 23%, Sore throat 4%, Rhinorrhoea 22%, Diarrhoea 9%, vomiting 10%.

Bloods: Largely unremarkable (although reports of lymphopenia unclear – state 14 patients lymphopenic but that this is 28%? – perhaps only 50 children had bloods, but this is not reported). Procalcitonin <0.5ng/L in 29/23 patients.

Radiology: Chest x-rays were performed for 35 children, of which 14/35 had interstitial abnormalities, 6/35 consolidation, and 1/35 pleural effusion: remaining 15/35 normal.

Comorbidities: There were 27/100 children with comorbidities – although it appears most had a mild illness (did not require respiratory support). This included 6 with cystic fibrosis, 4 neurological, 4 haematological, 4 with a syndrome, 3 with prematurity, 2 with cardiac conditions, 2 immunological, 2 ontological, and 1 metabolic disease.

Of the few patients that required respiratory support (9/100) a significant number had comorbidities (6/9), although the range was broad. This included two children with “epileptic encephalopathy”, one of whom also had CHARGE syndrome, a child with autism, a child with a VSD, a child with propionic acidemia, and a child with thrombocytopenia and frequent respiratory infections.

In comparison to Dong et al, the CDC data, and Lu et al, most features are broadly comparable. Some notable differences are a significantly larger number of infants in the Italian data (40% <1yr compared to 18% in Lu, 12% in Dong and 15.5% in CDC) and a slightly higher number of asymptomatic children (21% compared to 16% Lu, 13% Dong and 1.3% CDC). This most likely represents differences in the population cohorts presenting for testing among the different studies – comparison between cohorts is always difficult due to broad differences in the denominators used. There is no apparent difference in severity according to age in this Italian data set, whereas CDC noted increased hospitalization in children <1yr and Dong et al noted higher rates of severe or critical illness in infants <1yr.

Broadly speaking, this study confirms findings from China and the USA regarding the presence of significantly milder illness in children with COVID-19, including many asymptomatic children. A note is made of overrepresentation of children with comorbidities in this cohort (similar to the CDC data), although most of these still had mild illness. It is unclear if these children become more unwell, or are more likely to present to be tested.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, et al. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics.  https://doi.org/10.1016/j.jpeds.2020.05.007

This is a retrospective cohort study, describing 177 children and young adults with confirmed SARS-CoV-2 infection treated between March 15 and April 30 2020 at the Children’s National Hospital, Washington DC US. Children and young adults were detected because of presentation with symptoms at emergency departments, ambulatory clinics, inpatient units, or by referral for admission from external facilities. Of 177 patients, 44 (25%) were hospitalized, with 9 (5%) classified as critically ill. The aim of the study was to identify if any specific epidemiological or clinical features were associated with hospitalization, or critical care.  

This hospital served as a regional centre providing critical care for young adults aged 21 – 35 years, therefore not all patients would be termed “paediatric patients”. The overall patient age range was from 0.1 – 34.2 years, with a median of 9.6 years. Of the total group 12/177 were > 20 years of age, and 37/177 were between the ages of 15 – 20years. 

Age: There was no significant difference in age between the hospitalized and non-hospitalized patients, however in the hospitalized cohort, the critically unwell group were significantly older than the non-critically unwell hospitalized group (17.3 years versus 3.6 years; P =.04) 

Sex: There was equal representation (n = 177 52% male, 48% female), as well as in the hospitalised cohort (n=44 50% male, 50% female). However, males made up 67% of the critically ill cohort (n =9, 67% male, 33% female); but this was not statistically significant (p=0.26)

Race/ethnicity: data not provided, authors describe plans to do so in follow up analysis 

Underlying conditions: 39% of positive patients had an underlying condition (classified as asthma, diabetes, neurological, obesity, cardiac, haematological, oncological). Though asthma was the most common underlying condition (35/177 20%), it was not more common in hospitalized patients (7/44 16%), nor of those admitted, or those who were critically unwell (2/9, 22%). Though the numbers were small, specific underlying conditions such as neurological, cardiac, haematological, or oncological issues were more common in the hospitalised cohort than the non hospitalised cohort. They were not more common in the hospitalized critically ill compared with the hospitalised non critically ill. The authors noted there was no underlying condition present in 96/177 (55%) of overall SARS-CoV-2 infected patients overall, 16/44 (37%) of hospitalized patients and in 2/9 (22%) of critically ill patients.

Symptoms:  76% of infected patients presented with respiratory symptoms (rhinorrhea, congestion, sore throat, cough, or shortness of breath) with or without fever. Fever was present in 116/177 (66%) but was not more common in the infected hospitalized cohort (34/44, 77%) compared with the non-hospitalized cohort (82/133, 62%; p=0.46). 

Shortness of breath was more common in the hospitalized cohort (11/44, 26%) compared with non-hospitalized (16/133, 12%; p=0.04). Patients in the critically ill cohort were not more likely to have a fever or any other specific symptom compared with the non-critically ill cohort.

Critical Care: 9 patients required critical care. This represented 5% (9/177) of the total cohort and 20% (9/44) of admitted patients. 4 required intubation (3 ARDS, 2 multiple organ failure); 3 required BiPAP, 1 RAM cannula, and one high flow nasal cannula oxygenation. One patient had features consistent with the recently emerged Kawasaki disease-like presentation with hyper-inflammatory state, hypotension, and profound myocardial depression; a 4 year male with no underlying conditions. 

Summary:  A very clear description of 177 patients with SARS-CoV-2, in one large centre in Washington DC. 25% of patients needed hospitalisation and 5% needed critical care. Older teenagers and adults who required admission were overrepresented in requiring critical care. Though underlying conditions were more common in hospitalized patients, they were not significantly more common in the hospitalized patients who required critical care. Shortness of breath was the only symptom that was more common in hospitalized patients. No specific symptom was more apparent in patients needing critical care. One critically ill patient had features of the recently described hyperinflammatory state. 

de Lusignan, S., J. Dorward, A. Correa, N et al, (2020). “Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study.” Lancet Infect Dis. May 15th 2020, https://doi.org/10.1016/S1473-3099(20)30371-6

This study examines the demographic and clinical risk factors for testing positive for SARS-CoV-2 amongst patients within a large primary care network in the UK. This included tests done through Public Health England and the UK National Health Service (NHS) between January 28th and April 4th 2020 with clinical and sociodemographic data extracted from patients’ primary care medical records.

Overall 587 of 3802 patient tests returned a positive result for SARS-CoV-2. Of children 4.6% (23/499) tested positive compared with 17.1% (564/3303) of adults.

In a multivariate logistic regression, adults had significantly higher odds of a positive test compared with children; those aged 40-64 (aOR 5.36, 95% CI 3.28-8.76) and >75 (aOR 5.23, 95% CI 3.00-9.09) were at highest risk.
Male sex (aOR 1.55, 95% CI 1.27-1.89), social deprivation (aOR 2.03, 95% CI 1.51-2.71), and black ethnicity (aOR 4.75, 95% CI 2.65-8.51) were also associated with an increased risk of a positive SARS-CoV -2 test. Of clinical factors, only chronic kidney disease (aOR 1.91, 95% CI 1.31-2.78) and obesity (aOR 1.41, 95% CI 1.04-1.91) were significantly associated with testing positive. Surprisingly, active smoking was associated with lower odds of a positive test (aOR 0.49, 95% CI 0.34-0.71) possibly due to presentation confounding (i.e. presence of cough in chronic smokers prompting increased testing in this group).


This is the first study to utilise primary care data to assess risk factors for testing positive for SARS-CoV-2 in the community. The risk factors identified are similar to those associated with severe COVID-19 in hospitalised patients including increased age, male sex and obesity. The higher odds of a positive test in adults compared with children here are consistent with other studies suggesting children are at lower risk of SARS-CoV-2 infection compared with adults.

González Cortés, R., García-Salido, A., Roca Pascual, D. et al. A multicenter national survey of children with SARS-CoV-2 infection admitted to Spanish Pediatric Intensive Care Units. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-06146-8

The Spanish Paediatric Intensive Care Society have published their findings of 50 children admitted to 47 PICUs in Spain between 1st March 2020 and 1st May 2020 with SARS-CoV-2. More than 90% of PICUs in Spain were represented in this national database. During the study period there were no deaths from SARS-CoV-2 in children admitted to PICU in the participating PICUs.

The authors divided the children into two groups: those requiring ventilation and those not requiring ventilation, to assess for different characteristics between these groups. Fourteen (28%) of the children were ventilated.  Twenty-seven (54%) of the 50 children in the study had suspected PIMS-TS; these children were less likely to require mechanical ventilation (4 of the 27 required ventilation) than those without PIMS-TS. Statistical significance between the two groups was found for age (median age of 2.8 years in the ventilated group, compared to 8.6 years in the non-ventilated group); co-morbidities (12, 24%, of the 50 children had comorbidities; 8 of these were ventilated); and clinical presentation with respiratory difficulties or an ARDS-type picture.

Overall, of the 50 children, 23 (46%) had haemodynamic instability, 20 (40%) had respiratory difficulties and 1 (2%) had neurological symptoms. Shock was present in half of the children (25, 50%), renal failure in 8 (15%) and cardiac dysfunction in 17 (34%). 

Across the 50 children, white cell count (median 9.26, IQR 5.64-14.46), lymphocytes (median 1.02, IQR 0.42-2.59) and CRP (median 13.9, IQR 4.9-27) were not statistically different between ventilated and non-ventilated children.

These are the preliminary findings from this national registry of children with SARS-CoV-2 admitted to PICU in Spain. Further results and analysis will provide more information regarding critically unwell children with COVID-19.

M. A. De Ioris, A. Scarselli, M. L. Ciofi Degli Atti, et al. Dynamic viral SARS-CoV-2 RNA shedding in in children: preliminary data and clinical consideration of Italian regional center. J Pediatric Infect Dis Soc. May 23rd 2020, https://doi.org/10.1093/jpids/piaa065

This study at a paediatric hospital in Rome tracked SARS-CoV-2 shedding (nasopharyngeal, faecal, urinary and conjunctival) by following a cohort of 22 children during their hospital stay, collecting clinical and microbiological data. 

Study design:  The study ran from 16th March to 12th April in the COVID centre at Bambino Gesu Pediatric Hospital and collected data on 22 in-patients with an initial positive nasopharyngeal swab (either prior to admission or on admission).  RT-PCR for SARS-CoV-2 RNA on nasopharyngeal and conjunctival swabs and stool and urine samples were repeated every 2-3 days for each child while they were inpatients until they had two consecutive negative results in the absence of new symptoms.  Kaplan-Meier analysis was used to estimate the duration of symptoms and viral shedding for symptomatic patients: patients whose last swab/sample was still positive were censored at the date of the last swab.

Study population:  15/22 (68%) male, 7/22 (32%) female.  Median age 7 years (range 8 days to 17.5 years).  4/22 neonates (1/4 tested because mother positive and 3/4 tested because midwife positive).  2/22 comorbidity (Angelman syndrome, suspected genetic syndrome and autism).  13/22 patients were discharged before the end of the study period (median inpatient stay 7 days, range 3-15 days).  

Symptoms:  4/22 (18%) asymptomatic (including 2/4 neonates, the other 2/4 had low-grade fever and poor feeding).  18 symptomatic patients: 15/18 (83%) fever, 10/18 (55%) respiratory symptoms, 7/18 (39%) diarrhoea and vomiting, 3/18 (17%) seizure.  Symptoms had resolved in all 18 before discharge from hospital.  The median duration of symptoms was 8 days (range 2-21 days).  15/22 had a positive stool sample at admission: of these 7/15 (47%) had respiratory symptoms and 3/15 (20%) had diarrhoea and vomiting.

Viral shedding:  At diagnosis: 22/22 (100%) had positive nasopharyngeal swab (by definition), 15/22 (68%) had positive stool sample, 1/22 (5%) had positive urine sample (re-test 2 and 5 days later was negative; another patient had initial negative urine test but repeat 3 days later was positive) and 2/22 (9%) had positive conjunctival swab (both were negative 2-3 days later).  A detailed table charting the dates of inpatient stay, onset, and end of symptoms and positive/negative swabs/samples for each patient is supplied: the full screen of faecal, urinary and conjunctival sampling was performed at variable intervals after the initial positive nasopharyngeal swab (up to 5 days later in several cases).  For symptomatic patients:  (1) from date of symptom onset to negative nasopharyngeal swab: median 8 days (range 2-17 days) and (2) from date of symptom onset to negative stool sample: median 14 days (range 10-15 days).  The estimate of the persistence of viral shedding at day 14 from symptom onset for nasopharyngeal swab was 52% and for stool sample 31%.

The authors note the need to confirm the clinical relevance of faecal SARS-CoV-2 shedding in terms of the risk of transmission via the faeco-oral route.

Galván Casas, C., Català, A., Carretero Hernández, et al. (2020), Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. Accepted Author Manuscript. doi:10.1111/bjd.19163

This article from a team in Spain aimed to classify cutaneous manifestations of COVID-19 and relate them to other clinical findings. 

From 3rd of April 2020 to 16th of April 2020 they collected 429 cases but excluded 54 leaving a sample of 375 patients. A standardised questionnaire was used, photographs were taken and the questionnaires and photographs were independently reviewed by 4 dermatologists.

Data was collected by Spanish dermatologists from across the country most of whom had been redeployed from their usual dermatology posts.

Patients with an eruption of recent onset (previous 2 weeks) and no clear explanation, plus suspected or confirmed COVID-19 were included.

They describe 5 cutaneous manifestations.

Acral areas of Erythema-oedema with some vesicles or pustules: 19% of cases. These were more likely in children.

Other vesicular eruptions: 9%. May also affect the limbs and have a haemorrhagic content, and become larger or diffuse.

Urticarial lesions: 19%. Mostly distributed in the trunk or disperse. A few cases were palmar.

Other maculopapular: 47%. Some showed perifollicular distribution and varying degrees of scaling, Some had been described as similar to pityriasis rosea.

Livedo or necrosis: 6%

Strengths of this study are the large number of patients recruited and that four dermatologists independently reviewed the images. It adds to the understanding of skin manifestations of COVID-19, which may give additional information when trying to make a clinical diagnosis of COVID-19 if other symptoms are non-specific, also the cutaneous manifestations may persist for some time once other symptoms have resolved.

A weakness is the authors did not specify the age of the patients involved so the usefulness for paediatric patients is limited. Also, in some areas, diagnosis of COVID-19 infection could only be made clinically, based on symptoms as the ability to test patients was limited during the height of the pandemic. 

Xiong, X., G. T. Chua, S. Chi et al. A Comparison Between Chinese Children Infected with COVID-19 and with SARS. J Pediatr. June 18th 2020, https://dx.doi.org/10.1016%2Fj.jpeds.2020.06.041

In this study, 244 children with SARS-CoV-2 infection from Wuhan, China are compared to 44 children diagnosed with SARS (SARS-CoV-1) in in Hong Kong in 2003. 

The clinical details of this series of patients from Wuhan, previously described elsewhere, are compared with those of children with SARS-CoV-1. Overall children with SARS-CoV-2 were younger than those with SARS-CoV-1 (median age 82 months vs 160 months). Compared with SARS-CoV-1 patients, children with SARS CoV-2 were less likely to have symptoms (20.9% asymptomatic vs 0% of SARS-CoV-1), including fever (40.2% vs 97.7%), myalgia (37.6% vs 0.8%), and chills (32.6% vs 3.7%). 

Fewer children with SARS-CoV-2 required supplemental oxygen (4.7% vs 18.6%) and few in either cohort required mechanical ventilation (1.6% vs 2.3%). A single death occurred in a patient with SARS-CoV-2 (a 10 mo with intussusception) and no cases of PIMS-TS / MIS-C were identified amongst the 244 SARS-CoV-2 infected children from Wuhan.

The most striking difference is the milder clinical illness and relative lack of symptoms in children with SARs-CoV-2 compared with those with SARS-CoV-1. The lack of asymptomatic infections in SARS-CoV-1 is also notable, similar to findings in adults. Whilst the role of asymptomatic patients in the spread of SARS-CoV-2 is unresolved, the milder clinical illness in the majority of patients along with the demonstrated earlier peak in viral shedding relative to symptom onset and resultant role of pre-symptomatic transmission are likely major reasons for the continuing widespread transmission of SARS-CoV-2, where the outbreak of SARS-CoV-1 in 2003 was more readily contained.

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Please note that whilst all papers have been reviewed for the database and consideration of the overall updates, only selected papers which added new information at the time of publication had a formal review written. The sublists below also include the top ten papers for convenience.

Larger Cohort Clinical Papers 

Götzinger, F., B. Santiago-García, A. Noguera-Julián, et al.  “COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study.” Lancet Child Adolesc Health. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30177-2/fulltext

This European multi centre cohort study recruited from participating centres from  the Paediatric Tuberculosis Network European Trials Groups, to look at 582 cases of paediatric (<18 years old) SARS-CoV-2 infection in 21 countries with 77 healthcare centres. Centres from five additional countries reported no SARS-CoV-2 cases at the time of the study. The breakdown of centres included 454 (78%) tertiary, 54 (9%) secondary and 74 (13%) primary healthcare providers.

Cases were collected retrospectively from known cases prior to 1st April and prospectively between 1-24th April. Diagnosis was made on RT-PCR of SARS-CoV-2 alone. The age group of the population was young, with a median age of 5 (IQR 0.5-12) and 230 (40%) under 2 years of age. Just over half were male (n=311, 53%).

Index case data from history was included, with parents being the suspected index case for 324 patients (56%) and siblings accounting for 24 cases (4%). However a large number of cases (n=234, 40%) were either from someone outside of the immediate family or of unknown transmission.

The most common symptoms patients presented in were fever (n=379, 65%) and respiratory symptoms (n=313, 54% URTI and n=143, 25% LRTI). 128 (2%) had gastrointestinal (GI) symptoms and 40 (7%) had GI symptoms without respiratory symptoms. Asymptomatic patients accounted for 16% of all cases (92). There was confirmed viral co-infection in 5% (n=29) of patients. The study did not capture laboratory values. Chest x-ray was performed in 34% (n=198) of patients. Almost half of the x-rays showed findings consistent with pneumonia and ten (5%) of ARDS.

Of the patients in the study, a quarter (145) had pre-existing medical conditions. Twenty nine patients had pre-existing respiratory conditions (asthma accounting for 16) and malignancy was known in 27 patients. The study collected data on antiviral treatments administered however numbers were small and depended on local practice.

Across the cohort 363 patients (62%) required hospital admission, 48 (8%) required ICU admission. Factors increasing risk of ICU admission (n=48) were found to be age <1 month (n=7/48, 14.6%) the presence of any pre-existing medical condition (n=25/48 52%) and presence of lower respiratory tract infection signs at time of presentation (n=35/48, 73%). Mechanical ventilation was required by 25 patients (4%) and echo was used for 1 patient. Data on treatments given included antivirals: hydroxychloroquine (n=40, 7%), remdesivir (n=17, 3%), lopinavir-ritonavir (n=6, 1%) and oseltamivir (n=3, 1%). Other immunomodulators used were corticosteroids in 22 (4%), IvIG in 7 (1%), tocilizumab (n=4, 1%), anakinra (n=3, 1%) and siltuximab (n=1).

There were 4 deaths (0.69%), all of which were in children >10 years of age. Of the four deaths, one was an out of hospital cardiac arrest and two had pre-existing medical conditions; one patient had a stem cell transplant 15 months prior and another patient was managed palliatively due to their pre-existing illness. By time of end study 553 patients had made a full recovery and 25 patients had ongoing symptoms.

Overall, this is one of the first multi-national European studies of SARS-CoV-2 in children. Common symptoms included respiratory and fever but gastrointestinal symptoms were present in over one fifth of cases. Although eight percent of children required ICU admission, the case fatality rate was low at 0.69%. Children at greater risk of intensive care admission had pre-existing medical conditions, were less than 1 month old, or presented with lower respiratory tract symptoms. Asymptomatic infection occurred in 16% of cases. Given that at the time of the study, there were varying practices for screening criteria, it is likely that the true proportion of asymptomatic patients is higher (and true case fatality rate lower)

Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. N Engl J Med 2020;:NEJMc2005073. doi:10.1056/NEJMc2005073

This retrospective study examines the clinical characteristics of children with confirmed COVID-19 diagnosed at Wuhan Children’s hospital. There were 1391 children tested between Jan 28th and Feb 26th 2020 due to known contact with a case of COVID-19, of these 171 were confirmed to have SARSCoV-2.  Median age was 6.7yrs, and there was a relatively even spread amongst age groups. Children were predominantly male (104/171, 60.8%).

Clinical features: 83/171 had cough, 79/171 had pharyngeal inflammation (sore throat), 71/171 had fever. 15/171 had diarrhoea and 13/171 had rhinorrhoea. 49/171 were tachypnoeic on admission and 72/171 were tachycardia. Only 4/171 had Oxygen saturations <92% during hospitalisation. 0/31 infants <1yr were asymptomatic in this cohort, with rates of asymptomatic infection increasing with age. There were higher rates of pneumonia in infants (25/6), but the definition of this is unclear. We also have no information regarding co-infection with other viruses or bacteria.

Radiology: Not delineated into CXR or CT, but descriptions sound like CT findings. The most common was bilateral ground glass opacity (56/171) followed by unilateral patchy shadowing (32/171) and bilateral patchy shadowing (21/171). There were several children with radiographic pneumonia who were asymptomatic.

Bloods: The supplementary appendix contains lab results. Only 6/171 patients had lymphopaenia, the vast majority were in normal range (Med 2.9×109/L, IQR 2.2 – 4.4). CRP was elevated (>10mg/L) in 33/171 (Med 4, IQR 1.3 – 8) of which 27/33 had pneumonia.

Outcomes: 3 patients required ITU admission and intubation. All 3 had comorbidities, including hydronephrosis, leukaemia and intussusception. The child with intussusception suffered multiorgan failure and died after 4 weeks. The cause of death is not clear from the report. As of writing 149 patients had been discharged with 21 stable in the general wards.

Parri N, Lenge M, Buonsenso D; Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group. Children with Covid-19 in Pediatric Emergency Departments in Italy [published online ahead of print, 2020 May 1]. N Engl J Med. doi:10.1056/NEJMc2007617

This report is of confirmed COVID-19 infections in children under 18 years of age who presented to a research collaboration of 17 paediatric emergency departments in Italy between March 3rd and March 27th. The median age was 3.3 years and 57/100 were male. Children under 1 year were overrepresented (40%) followed by children >10yrs (24%).

Helpfully they categorise their patients according to criteria from Dong et. al (see review in Epidemiology top 10): Asymptomatic 21%, Mild 58%, Moderate 19%, Severe 1% and Critical 1%. Only 12% of patients appeared ill on assessment. Interestingly only 4% of patients had Oxygen saturations <94%. Only 38% of children needed admission for severity of illness. There were no deaths. The supplementary appendix includes a huge amount of detailed analysis of the cases, which are summarised below

Clinical features: Fever 54%, Cough 44%, Feeding difficulty 23%, Sore throat 4%, Rhinorrhoea 22%, Diarrhoea 9%, vomiting 10%.

Bloods: Largely unremarkable (although reports of lymphopenia unclear – state 14 patients lymphopenic but that this is 28%? – perhaps only 50 children had bloods, but this is not reported). Procalcitonin <0.5ng/L in 29/23 patients.

Radiology: Chest x-rays performed for 35 children, of which 14/35 had interstitial abnormalities, 6/35 consolidation and 1/35 pleural effusion: remaining 15/35 normal.

Comorbidities: There were 27/100 children with comorbidities – although it appears most had mild illness (did not require respiratory support). This included 6 with cystic fibrosis, 4 neurological, 4 haematological, 4 with a syndrome, 3 with prematurity, 2 with cardiac conditions, 2 immunological, 2 oncological and 1 metabolic disease.

Of the few patients who required respiratory support (9/100) a significant number had comorbidities (6/9), although the rage was broad. This included 2 children with “epileptic encephalopathy”, one of whom also had CHARGE syndrome, a child with autism, a child with a VSD, a child with propionic acidemia, and a child with thrombocytopenia and frequent respiratory infections.

One of the strengths of this study is comparisons across other studies of clinical features of COVID-19 in children. In comparison to Dong et al, CDC data and Lu et al, most features are broadly comparable. Some notable differences are a significantly larger number of infants in the Italian data (40% <1yr compared to 18% in Lu, 12% in Dong and 15.5% in CDC) and a slightly higher number of asymptomatic children (21% compared to 16% Lu, 13% Dong and 1.3% CDC). This most likely represents differences in which population cohorts presented for testing among the different studies – comparisons between cohorts is always difficult currently due to broad differences in the demoninators used. Notably there is no apparent difference in severity according to age in this Italian data, whereas CDC noted increased hospitalisation in children <1yr and Don’t et al noted higher rates of severe or critical illness in infants <1yr.

Broadly speaking this study confirms findings from China and the USA regarding significantly milder illness in children than adults with COVID-19, including many asymptomatic children. Note is made of overrepresentation of children with comorbidities in this cohort (similar to CDC data), although most of these still had mild illness – it is unclear if these children become more unwell, or are more likely to present to be tested.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, et al. Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of Pediatrics.  https://doi.org/10.1016/j.jpeds.2020.05.007

This is retrospective cohort study, describing 177 children and young adults with confirmed SARS-CoV-2 infection treated between March 15 and April 30 2020 at Children’s National Hospital, Washington DC US. Children and young adults were detected through symptomatic presentation at emergency departments, ambulatory clinics, inpatient units, or by referral for admission from external facilities. Of 177 patients, 44 (25%) were hospitalised, with 9 (5%) classified as critically ill. The aim of the study was to identify if any specific epidemiological or clinical features associated with hospitalisation, or critical care.  

Of note this hospital served as a regional centre for providing critical care for young adults aged 21 – 35 years, therefore not all patients would be termed “paediatric patients”. Overall patient age range was from 0.1 – 34.2 years, with a median of 9.6years. Of the total group 12/177 were > 20 years of age, and 37/177 were between age of 15 – 20years. 

Age: There was no significant difference in age between the hospitalised and non-hospitalised patients, however in the hospitalised cohort, the critically unwell group were significantly older than the non-critically unwell hospitalised group (17.3 years versus 3.6 years; P =.04) 

Sex: There was equal representation in total cohort showed (n = 177 52% male, 48% female), as well as the hospitalised cohort (n=44 50% male, 50% female). However males made up 67% of the critically ill cohort (n =9, 67% male, 33% female); but this was not statistically significant (p=0.26)

Race/ethnicity: data not provided, authors describe plans to do so in follow up analysis 

Underlying conditions: 39% of positive patients had an underlying condition (classified as asthma, diabetes, neurological, obesity, cardiac, haematological, oncological). Though asthma was the most common underlying condition (35/177 20%), it was not more common in hospitalised patients (7/44 16%), nor of those admitted, those who were critically unwell (2/9, 22%). Though the numbers where small, specific underlying conditions such as neurological, cardiac, haematological, or oncological underlying conditions were more common in the hospitalised cohort than the non hospitalised cohort. But were not more common in the hospitalised critically ill compared with the hospitalised non critically ill. The authors noted there was no underlying condition present in 96/177 (55%) of overall SARS-CoV-2 infected patients overall, 16/44 (37%) of hospitalized patients and in 2/9 (22%) of critically ill patients.

Symptoms:  76% of infected patients presented with respiratory symptoms (rhinorrhea, congestion, sore throat, cough or shortness of breath) with or without fever. Fever was present in 116/177 (66%) but was not more common in the infected hospitalized cohort (34/44, 77%) compared with the non-hospitalized cohort (82/133, 62%; p=0.46). 

Shortness of breath was more common in the hospitalized cohort (11/44, 26%) compared with non-hospitalized (16/133, 12%; p=0.04). Patients in the critically ill cohort were not more likely to have fever or any other specific symptom compared with the non-critically ill cohort.

Critical Care: 9 patients required critical care; which represented 5% (9/177) of total cohort and 20% (9/44) of admitted patients. 4 required intubation (3 ARDS, 2 multiple organ failure); 3 required BiPAP, 1 RAM cannula and 1 High flow nasal cannula. One patient had features consistent with the recently emerged Kawasaki disease-like presentation with hyper-inflammatory state, hypotension and profound myocardial depression; a 4 year male with no underlying conditions. 

Summary:  A very clear description of 177 patients with Sars CoV 2, in one large centre in Washington DC. 25% of patients needed hospitalisation and 5 % needed critical care. Older teenagers and adults who required admission, were then overrepresented in requiring critical care. Though underlying conditions were more common in hospitalised patients, they were not significantly more common in the hospitalised patients who required critical care. Shortness of breath was the only symptom that was more common in hospitalised patients than non-hospitalised patients. No specific symptom was more apparent in patients needing critical care. One critically ill patient had features of recently described hyperinflammatory state. 

de Lusignan, S., J. Dorward, A. Correa, N et al, (2020). “Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study.” Lancet Infect Dis. May 15th 2020, https://doi.org/10.1016/S1473-3099(20)30371-6

This study examines the demographic and clinical risk factors for testing positive for SARS-CoV-2 amongst patients within a large primary care network in the UK. This included tests done through Public Health England and the UK National Health Service (NHS) between January 28th and April 4th 2020 with clinical and sociodemographic data extracted from patients’ primary care medical records.

Overall 587 of 3802 patient tests returned a positive result for SARS-CoV-2. Of children 4.6% (23/499) tested positive compared with 17.1% (564/3303) of adults.

In multivariate logistic regression, adults had significantly higher odds of a positive test compared with children; those aged 40-64 (aOR 5.36, 95% CI 3.28-8.76) and >75 (aOR 5.23, 95% CI 3.00-9.09) were at highest risk.
Male sex (aOR 1.55, 95% CI 1.27-1.89), social deprivation (aOR 2.03, 95% CI 1.51-2.71) and black ethnicity (aOR 4.75, 95% CI 2.65-8.51) were also associated with an increased risk of a positive SARS-CoV -2 test. Of clinical factors, only chronic kidney disease (aOR 1.91, 95% CI 1.31-2.78) and obesity (aOR 1.41, 95% CI 1.04-1.91) were significantly associated with testing positive. Surprisingly active smoking was associated with lower odds of a positive test (aOR 0.49, 95% CI 0.34-0.71) possibly due to presentation confounding (i.e. presence of cough in chronic smokers prompting increased testing in this group).


This is the first study to utilise primary care data to assess risk factors for testing positive for SARS-CoV-2 in the community. The risk factors identified are similar to those associated with severe COVID-19 in hospitalised patients including increased age, male sex and obesity. The higher odds of a positive test in adults compared with children here are consistent with other studies suggesting children are at lower risk of SARS-CoV-2 infection compared with adults.

Parri, N., A. M. Magistà, F. Marchetti, et al, (2020). “Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian Pediatric Research Networks.” Eur J Pediatr: 1-9. https://doi.org/10.1007/s00431-020-03683-8

This study is published as a short communication describing the clinical presentations and outcomes in children with identified Covid-19 in 61 centres in Italy between 3rd and 26 March 2020.

Study Design: A retrospective study coordinated by the CONFIDENCE and COVID-19 Italian Paediatric Study Network’s involving 53(86.9%) hospitals and 8(13.1%) outpatient centres in 10 mainly northern regions. All children (0-18 years) diagnosed positive on screening and testing for Covid-19 by nasal/nasopharyngeal RT-PCR assay were entered into the study. Clinical, laboratory and imaging data was collected on standardised forms. 

Study Population: 130 children and adolescents recruited (112 hospital;18 outpatient). <2 years 41 (31.5%), 2-9 years 35 (26.9%)’10-17 years 45 (34.6%). Male 73 (56.2%). Female 57(43.8%) p=0.47.

Comorbidities 34 (26.2%) most frequent cardiovascular, respiratory and neuromuscular. No information on ethnicity. One patients data unobtainable.

Disease Severity: The majority of subjects were categorised as being asymptomatic or having mild disease 98/130 (75.4%). 11 (8.5%) were moderate severity, 11 severe and 9 (6.9%).critical. 75 (57.7%)were hospitalised  with 15.(11,5%) needing respiratory support (5 needing oxygen, 2 non invasive ventilation and 2 mechanical ventilation). 9 cases were admitted to ICU with 6 being less than 6 months. 3 of the latter were less than 2 months and did not require respiratory support. Children less than 6 months had an increased risk of critical disease than older children: 6/35 (17.1%) vs 3/86 (3.5%) p=0.34. OR 5.6 CI 1.3 to 29.1.

Symptoms: Common symptoms were fever 67(51.5%), dry cough 38(29.2%) and productive cough 16(12.3%). Other symptoms were rhinorrhoea25(19.2%), respiratory distress 17(13%), vomiting 15(11.5%);diarrhoea 10(7.6%); sore throat 9(6.9%). Thoracic pains (3%), somnolence, febrile convulsions (1.5%) and lower limb pains (1.5%) were reported as novel symptoms.

Oxygen saturation at presentation:  91-92% 1(0.8%). <90 1(0.8)

 Radiology: 41 (31.5%) of children had CXRs. These were normal in 15 (36.6%). The commonest abnormalities were ground-glass opacities in 17 (41.5%). Focal consolidation was seen in 4 (9.8%).

Laboratory:  71 children were reported to have had laboratory tests. The authors report leukopenia (WCC %<5.5×109) and lymphopenia (<1.2×109) in 7/19 patients and 3/19 patients, respectively. They report elevation in aspartate transaminase >50U/l in 11/60 (18.3%) and alanine tranasaminase >45U/l in 8/68 (11.8%).

Outcomes: There were no deaths and all children were reported to have recovered.

Comment: The study obtained data on all but one child found Covid-19 positive in this largely hospital based population. The authors acknowledge that there is a bias toward more ill patients with their population than community studies and this may explain the 57.7% admission rate. Also this is reflected in the amount of comorbidity. However, the majority of patients were either asymptomatic or had mild disease and small numbers required respiratory support or ITU. The authors identify the increased likelihood of critical disease in those less than 6 months and their being the majority of ICU cases. They also comment on new presenting symptoms (thoracic pain, somnolence, febrile convulsions and lower limb pains).

de Ceano-Vivas M, Martín-Espín I, del Rosal T, et al. SARS-CoV-2 infection in ambulatory and hospitalised Spanish children, Arch Dis Child, doi:10.1136 / archdischild-2020-319366 

Study design: A retrospective case series of all children seen at a tertiary centre, who were found to have positive PCR for SARS-CoV-2.  Testing for SARS-CoV-2 was only conducted in those children who had respiratory symptoms and “criteria for hospitalisation” or who had “underlying chronic pathology”. Children with mild symptoms were not tested even if there was a confirmed case in the household. Comparisons were made between the characteristics of those admitted to hospital and those treated as outpatients. The study was conducted between March 11th and April 9th 2020 at Hospital La Paz, Madrid, Spain.

Inclusion criteria: All children who underwent PCR for SARS-CoV-2 in nasopharyngeal smear, N=349.  Of whom 58 (16.6%) had a positive PCR and were the cases analysed.

Key findings: Of the 58 cases: Male 37 (63.8%), Median age 35.5 months (range 3.3-146), Underlying conditions 23 (39.7%), Temperature >39.7degC 41 (70.7%), Cough 42 (72.4%), Rhinorrhoea 33 (56.9%), Breathing difficulty 10 (17.2%), Vomiting 9 (15.5%), Headache 8 (13.8%), Loss of taste 1 (1.7%), Anosmia 1 (1.7%). 

Radiology: 40 (69%) had a CXR of which 35 (87.5%) were abnormal: Perihilar infiltrates, ground-glass pattern, lobar or multilobar consolidation. 

Bloods: 43 (74.1%) had a blood test, median WCC 9145/mm3, median lymphocyte count 2390/mm3. 

Outcomes: 33 were hospitalised and 25 were treated as outpatients. Of the inpatients, 14 (42.4%) received oxygen therapy for a median of 3 days. 5 were admitted to the PICU (15% of those hospitalised): 3 with severe COVID-19, 1 with a hypertensive crisis and 1 with diabetic ketoacidosis.  31 (53.4%) were treated with hydroxychloroquine, 3 patients were treated with remdesivir. 2 patients with an inflammatory syndrome were also treated with tocilizumab. There was 1 death of a 5/12 old infant with dilated cardiomyopathy and Hurler’s syndrome. The comparisons between the inpatient and outpatient group provide almost no additional useful information.

Comment: As the authors concede, the retrospective nature of the study is a significant weakness. Patients were selected for testing on the basis of symptoms and/or underlying conditions and many other children who could have been infected were never tested. The study is useful in describing the range of symptoms, treatment and outcome in the large selected group of children who tested positive for SARS-CoV-2. It does not, however, add anything new to what is already known about the condition in children.

Chen C. Coronavirus Disease-19 Among Children outside Wuhan, China [Internet]. Lancet Child and Adolescent medicine; Available from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3546071

A pre-print, the information should be treated with caution until it has undergone peer review. This is a prospective case series of 31 paediatric cases of COVID-19 diagnosed at the Shenzen Third Peoples hospital between Jan 16th and Feb 19th 2020. This made up 7.9% of all cases diagnosed in Shenzen. They were all confirmed by PCR. None had been exposed to the seafood market in Wuhan. The patients received nebulised interferon and, IV ribavirin or oral lopinovir/ritonavir. The median age was 6.75, with most patients (41.9%) aged 5-9. Followed by 0-4yrs (32.2%) and 10-14yrs (19.4%). 41.9% were male.

Clinical features: 12/31 Children were asymptomatic. Fever was observed in 14/31, Cough in 13/41, Sore throat in 2/31, Rhinorrhoea in 22/31 and diarrhoea in 2/31. Median duration of fever was 2 days, with a range of  1–9 days. Bloods: Lymphopaenia was not observed. Lymphocytosis occurred in 17/31 patients. CRP was elevated in 4/31 patients. Radiology: On admission 64.5% of CT were normal, with 25% having unilateral pneumonia and 9.7% having bilateral. During hospitalization one child developed a unilateral pneumonia whose radiography was initially normal. Outcome: 23 children had been discharged at the time of writing, and the remainder were well and afebrile.

Garazzino S, Montagnani C, Dona D, et al. Multicentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April 2020. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin 2020; 25(18). https://dx.doi.org/10.2807%2F1560-7917.ES.2020.25.18.2000600

This rapid communication reports the preliminary results of an Italian multicentre study involving 11 of 13 exclusively paediatric hospitals and 51 of 390 paediatric units across Italy (mainly in central and northern Italy).  Retrospective data collection began on 25 March 2020.

Study design:  Data to 10 April 2020 collected by participating physicians and hospitals for all paediatric patients (aged 1 day to 17 years) with at least one RT-PCR SARS-CoV-2 positive nasal/pharyngeal swab AND adequate follow-up considered necessary by the clinician to define the final outcome (usually 2 wks).

Findings:  Data collected for 168 children and adolescents with documented COVID-19: 

Gender:  94/168 male (55.9%) and 74/168 female (44.1%)

Age:  median 2.3 yrs (IQR 0.3-9.6 yrs, range 1 day-17.7 yrs, mean 5 yrs.  <1 yr:  66/168 (39.3%), of which 15/168 neonates (6.9%). 1-5 yrs:  38/168 (22.6%). 6-10 yrs:  24/168 (14.3%). 11-17 yrs:  40/168 (23.8%)

Hospitalised: 110/168 (65.1%): <1 yr:  52/66 (78.8%). 1-5 yrs:  24/38 (63.2%). 6-10 yrs:  13/24 (54.2%). 11-17 yrs:  21/40 (52.5%)

Comorbidities:  33/168 (19.6%):  chronic lung disease 7, congenital malformations or complex genetic syndromes 14, cancer 4, epilepsy 5, gastrointestinal disorders 2, metabolic disorders 1, immunosuppression 4, immunocompromise 3.  The hospitalisation rate was similar between children with comorbidities (23/33, 70%) and those without (87/135, 64%).

Source of infection:  Close contact with a COVID-19 infected person outside the family was rarely reported.  113/168 (67.3%) of children had at least one parent who tested positive for SARS-CoV-2 infection.  Symptom onset in relatives preceded symptoms in the infected child by 1 to 14 days in 88/113 (77.8%).

Symptoms:  4/168 (2.4%) asymptomatic. Fever (37.5 to 39°C) 138/168 (82.1%), cough 82/168 (48.8%), rhinitis 45/168 (26.8%), diarrhoea 22/168 (13.1%), dyspnoea 16/168 (9.5%), pharyngitis 9/168 (5.4%), vomiting 9/168 (5.4%), conjunctivitis 6/168 (3.6%), chest pain 4/168 (2.4%), fatigue 3/168 (1.8%), non-febrile seizures 3/168 (1.8%, all 3 had a known history of epilepsy), febrile seizures 2/168 (1.2%, 1 with a history of febrile seizures and 1 with first episode of febrile seizures as onset of COVID-19).

Blood results:  Of the children who had blood tests, 47/121 (38.8%) had CRP > 0.5 mg/dl.  Other abnormal findings were rare.

Complications:  33/168 (19.6%) developed complications: interstitial pneumonia 26/168 (15.5%), severe acute respiratory illness 14/168 (8.3%),  peripheral vasculitis 1/168 (0.6%)

No child underwent a chest CT scan; pneumonia was assessed using X-ray or ultrasound in 75/168.  

Co-infection:  Documented in 10/168 (5.9%), including 3 RSV, 3 rhinovirus, 2 EBV, 1 influenza A, 1 non-SARS coronavirus infection, 1 Strep pneumoniae.

Treatment:  16/168 (9.5%) required non-invasive oxygen treatment.  2 were admitted to ICU for mechanical ventilation (1 preterm neonate and a 2-month-old with congenital heart disease).  49/168 (29.2%) children (those with more severe illness) received experimental SARS-CoV-2 treatments, including lopinavir/ritonavir, hydroxychloroquine and/or azithromycin/clarithromycin, systemic steroids.

All children, including those with comorbidities, recovered fully and there were no sequelae reported at the time of submission.  This paediatric data is in contrast to the high number of cases and case-fatality rate seen in adults in Italy.  Children comprised a marginal percentage of those hospitalised in Italy with SARS-CoV-2 infection.

Zhang C, Gu J, Chen Q, et al. Clinical Characteristics of 34 Children with Coronavirus Disease-2019 in the West of China: a Multiple-center Case Series. doi:10.1101/2020.03.12.20034686

A pre-print, the information should be treated with caution until it has undergone peer review.

This is a further retrospective case study looking at 34 children with confirmed COVID-19 between Jan 1st and Feb 25th 2020 in 4 hospitals in Western China. They were aged 1 month to 12 years.

Clinical features: The most common symptom was fever (26/34) followed by cough (20/34), followed by vomiting (4/34) and diarrhoea (4/34). A significant number had co-infections (16/34) including Mycoplasma pneumoniae (9/34), influenza A or B (12/34) and 2/34 were mononucleosis. One child had a nephroblastoma and one had asthma. The median incubation period was 10 days (IQR 7.75 – 25.25) and median 3 days (IQ 2 – 4) from admission to fever resolution

Bloods: Lymphocytosis was most common (17/34). CRP was not significantly elevated (median 7.56ml/L, IQR 1.21 – 15.13), but was >5 for 20/34, and procalcitonin was not significantly elevated either (0.6, 0.03 – 0.07)

Radiography: On chest CT 14/34 had patchy shadows bilaterally, 14/34 unilaterally, and 6 had normal CT chest.

Qiu, Haiyan et al, Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. The Lancet Infectious Diseases, Volume 0, Issue 0 DOI:https:// doi.org/10.1016/S1473-3099(20)30198-5

Qui and colleagues retrospectively identified 36 children with an EMR diagnosis of COVID-19, during the period Jan 17 through March 1st, at three hospitals in Zhejiang, China, a province 900km to the east of Wuhan. Diagnosis was made by COVID-19 RT PCR for all patients presenting with fever, cough and radiographic presentation, or if there was a history of exposure to an infected individual.

For the mild cohort, 28% of patients were asymptomatic, with moderate cases more likely to have fever of 38oC or higher (47%), cough (24%), vomiting or diarrhoea (10%) or headache (10%). More than half (53%) of patients had ground-glass opacities on CT scan, meeting the case definition for Moderate illness. Key laboratory values of note include lymphopaenia, leukocytopaenia and increased procalcitonin as all associated with moderate illness. No patients in this cohort were hypoxaemic as a result of their pneumonia.

The authors also draw comparisons between adults and children with COVID-19 (less severe illness, less likely to have abnormal investigations), as well as comparing the clinical features and severity of COVID-19 with SARS (milder symptoms and severity) and H1N1 influenza (fewer symptoms, more frequent pneumonia) in children. Wisely, Qui & colleagues note the high rate of findings that are not clinically obvious, and the high proportion of asymptomatic cases make for very challenging case identification in the absence of clear epidemiologic information. “This finding suggests a dangerous situation if community-acquired infections occur.”

Zheng F, Liao C, Fan Q-H, et al. Clinical Characteristics of Children with Coronavirus Disease 2019 in Hubei, China. Curr Med Sci 2020;:1–6. doi:10.1007/ s11596-020-2172-6

This is a retrospective case series of 25 children <14 years of age hospitalised with COVID-19 from 10 hospitals across the Hubei province between February 1st and February 10th 2020. It is unclear how the cases were ascertained. 14/25 were male (54%) and the median age was 3yrs (IQR 2-9yrs). Most patients were <3 years (40%). 2 patients had a background of repaired congenital heart disease (both infants), although we have no more detail than this. Both of these children went on to develop critical illness.

Clinical features: 13/25 (52%) had fever, 11/25 (44%) had cough, 3/25 (12%) had diarrhoea, and 2/25 (8%) had nasal congestion, vomiting, breathlessness or abdominal pain. 

Bloods: Inflammatory markers were not particularly raised, with a median CRP of 14.5mg/L (IQR 0.93 – 25). 10/25 (40%) patients had lymphopenia.

Radiology: CT chest was normal in 8/24 (32%) with unilateral involvement in 5/24 (20%) and bilateral in 12/24 (48%). Changes typically showed patchy shadows. Younger children appeared more likely to have bilateral lung findings than older children. 

Co-infection: Other organisms identified included Mycoplasma pneumoniae (3/25, 12%), Influenza B (2/25, 8%) and one of the 2 critically ill children had Enterobacter aerogenes.

PICU Clinical Papers

González-Dambrauskas S, Vásquez-Hoyos P, Camporesi A, et al. Pediatric critical care and COVID19. Pediatrics. 2020; doi: 10.1542/peds.2020-1766

In preprint, González-Dambrauskas et al describe 17 children with COVID-19 admitted to international PICUs in Chile, Colombia, Italy, Spain and USA, in April 2020. These are interim results from the CAKE (Critical Coronavirus And Kids Epidemiologic) Study, recruiting between April and December 2020 from almost 60 PICUS in 20 countries. As well as describing the clinical details of each child in detail, this paper also describes four children with myocarditis associated with covid-19.

The 17 children predominantly presented with cough and fever (53% had cough, 76% had fever). Comorbidities were common in 71% of children, including underlying respiratory, cardiac, renal, liver or neurological disorders. Six children (35%) had gastrointestinal (GI) symptoms at presentation. 

Of the four children with myocarditis, all were based in Europe, none had previous cardiac disease, and all presented with fever and GI symptoms. One also had a rash and conjunctivitis. These children all developed myocarditis early in their clinical picture, with average duration of symptoms prior to presentation of 3.5 days. All four children received IVIG. Three of these children also required inotropic support; one child also developed ARDS and acute kidney in addition to myocarditis, requiring non-invasive ventilation but not renal replacement therapy. None of the four children with myocarditis required mechanical ventilation. All four children survived to discharge home, with a mean hospital length of stay of 13.5 days.

González Cortés, R., García-Salido, A., Roca Pascual, D. et al. A multicenter national survey of children with SARS-CoV-2 infection admitted to Spanish Pediatric Intensive Care Units. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-06146-8

The Spanish Paediatric Intensive Care Society have published their findings of 50 children admitted to 47 PICUs in Spain between 1st March 2020 and 1st May 2020 with SARS-CoV-2. More than 90% of PICUs in Spain were represented in this national database. During the study period there were no deaths from SARS-CoV-2 in children admitted to PICU in the participating PICUs.

The authors divided the children into two groups: those requiring ventilation and those not requiring ventilation, to assess for different characteristics between these groups. Fourteen (28%) of the children were ventilated.  Twenty-seven (54%) of the 50 children in the study had suspected PIMS-TS; these children were less likely to require mechanical ventilation (4 of the 27 required ventilation) than those without PIMS-TS. Statistical significance between the two groups was found for age (median age of 2.8 years in the ventilated group, compared to 8.6 years in the non-ventilated group); co-morbidities (12, 24%, of the 50 children had comorbidities; 8 of these were ventilated); and clinical presentation with respiratory difficulties or an ARDS-type picture.

Overall, of the 50 children, 23 (46%) had haemodynamic instability, 20 (40%) had respiratory difficulties and 1 (2%) had neurological symptoms. Shock was present in half of the children (25, 50%), renal failure in 8 (15%) and cardiac dysfunction in 17 (34%). 

Across the 50 children, white cell count (median 9.26, IQR 5.64-14.46), lymphocytes (median 1.02, IQR 0.42-2.59) and CRP (median 13.9, IQR 4.9-27) were not statistically different between ventilated and non-ventilated children.

These are the preliminary findings from this national registry of children with SARS-CoV-2 admitted to PICU in Spain. Further results and analysis will provide more information regarding critically unwell children with COVID-19.

Grasselli, G et al. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. doi:10.1001/jama.2020.5394 Published online April 6, 2020.

This is a retrospective case series of 1591 consecutive patients with laboratory-confirmed COVID-19 referred for ICU admission to the regional ICU coordinator of the Lombardy ICU Network, and treated at one of the ICUs of the 72 hospitals in the network. Patients were recruited between 20/02/2020 and 18/03/2020 with follow-up on 25/03/2020. Data was collected via telephone. Of the nearly 1600 patients referred for ICU admission, only 4 were between 0 and 20 years of age, with a median age of 16 and interquartile range of 14 to 19 years of age. Three of the four patients (75%) were male and three of the four had comorbidities (specific details not given).

Two required mechanical ventilation. It’s important to note that the patients in this study were those admitted to ICU and not patients on medical wards, in the ED or in the community so the high percentage of ventilated patients in this study is not a reflection of the other patients in the region with SARS-CoV-2. These two patients had relatively low oxygen requirements with an FiO2 of 30% and 50%; relatively low PEEPs of 5 and 14 mmHg; and favourable PaO2/FiO2 ratios of 195 and 323, placing these two patients in the mild to moderate ARDS severity scores (for more information on PaO2/FiO2 ratios have a look at the LITFL explanation at https://litfl. com/pao2-fio2-ratio/). None of the four patients in the 0-20 year old category received ECMO. Information on disposition was only available for two of the four patients. None of these patients died. Two remained on ICU on 25/03/2020 at time of follow-up.

What can we take from this study? As the study recruited patients admitted to ICU, the numbers of adolescent patients in this case series is low at only four, with an age range of 16 to 19. The data was collected retrospectively via telephone making it difficult to draw robust conclusions. However, we can see that compared to the older groups of patients in the study, ventilation requirements were lower. Three of the four adolescent patients had comorbidities, which might suggest that children and adolescents without comorbidities in the Lombardy region were less severely unwell and did not require ICU admission.

Oualha, M., M. Bendavid, L. Berteloot, et al.  “Severe and fatal forms of COVID-19 in children.” Archives de Pediatrie, June 4th 2020, https://doi.org/10.1016/j.arcped.2020.05.010

This paper describes the clinical presentation and course of the 27 children and young people with COVID who required paediatric intensive care in and around Paris  at the height of the coronavirus peak in France. The total population of all ages of the Ile de France , the region for which this centre is responsible for tertiary paediatric referrals, is around 12 million. During the time covered by the study, there were around 5000 COVID deaths in France, with the Ile de France region being the hardest hit.

This study focuses on 27 children unwell enough to need high dependency care during active COVID infection. The criteria for admission were oxygen requirement > 1L/min or underlying disease. The cohort of 27 were admitted within days of onset of first symptoms and 24 were positive for COVID-19 by PCR of nasal swabs. This is consistent with active virus, rather than PIMS-TS, the Kawasaki like post-COVID syndrome.

 24 had respiratory disease, mostly with radiological or CT findings consistent with COVID.  6 had cardiovascular disease and 4 renal problems.  

9 required invasive ventilation with median duration 5 days.  10 received non-invasive ventilation and 23 were treated with oxygen. 4 received catecholamines, one ECMO and one renal replacement therapy.  The median length of hospital stay was 6 days.

Mean laboratory findings in the group were of elevated CRP, procalcitonin, fibrinogen and D-dimers, consistent with an inflammatory and prothrombotic state.  Neutrophil and lymphocyte counts were normal. T cell subsets and cytokine levels were not measured.

70% had underlying conditions, but the spectrum was different from adult experience, with neurological and respiratory problems or sickle cell disease being most common.

Three of the five who died had previously been in good health. A teenage girl whose clinical course was suggestive of the cytokine storm seen in adults died within hours of admission. A teenage boy and a 6 year old girl co-infected with other pathogens both died after long PICU stays. 

This description confirms that severe illness is rare in children with COVID and shows that even those admitted for HDU care had a shorter illness and better prognosis than that seen in adults. Nonetheless, occasional children do suffer a prolonged illness with multi-organ dysfunction.

Lanyon, N., P. du Pré, T. Thiruchelvam, S. Ray, M. Johnson and M. J. Peters (2020). “Critical paediatric COVID-19: varied presentations but good outcomes.” Arch Dis Child. https://dx.doi.org/10.1136/archdischild-2020-319602

In this letter from Great Ormond Street Hospital for Children, London, 24 children, who tested positive for Covid-19, were admitted to the intensive care unit between 26th March 2020 and 31st May 2020. Thirteen of these had PIMS-TS. This letter describes the clinical features of the remaining 11.

These 11 had a median age of 5 years (range 0.4-11), 9 were boys, 9 had pre-existing medical conditions, and 4 came from the BAME community. The primary presenting feature was cough 6, apnoea 3, fever 10, gastrointestinal 6 and seizures 3

In all 11 inflammatory markers were raised, median ferritin 898 (range 254-1991), CRP 158 (27-449), LDH 1594 (802-4264) D-Dimer 158 (27-449). 4 children fulfilled the criteria for paediatric acute respiratory distress syndrome, the remaining 7 were admitted to PICU for other reason than respiratory failure. A variety of different forms of respiratory support were provided, invasive mechanical ventilation 9, prone position 4, inhaled pulmonary vasodilators 4, HFOV 2 and ECMO none. 5 children received remdesivir and 6 prophylactic anticoagulation.

All 11 children survived to hospital discharge. The authors conclude “While children can present to PICU with a pattern of illness similar to adult COVID-19 disease this is rare and three quarters of them had risk factors for respiratory infection. A larger number were found to be SARS-COV-2 coincidentally.”

Clinical Dermatology COVID-19

Colmenero, I., C. Santonja, M. Alonso-Riano, et al. “SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultraestructural study of 7 paediatric cases.” The British journal of dermatology. June 20th 2020, https://doi.org/10.1111/bjd.19327

Anecdotally, chilblains seem to be associated with Covid-19 in children and young adults. This case series from Madrid describes 7 children (age 11-17) presenting with chilblains on their toes during the pandemic. None had underlying conditions likely to cause chilblains, and in Spain, cold weather wasn’t responsible. The chilblains looked typical, caused only minor pain and itching, and all resolved spontaneously. All had skin biopsies, which showed a variety of inflammatory and vasculitic changes on histology, typical of chilblains: they also looked specifically for SARS-CoV-2 particles in the endothelium of the dermal vessels using immunohistochemistry and electron microscopy and found the virus in all of them.

What is remarkable is that all the children were systemically well, had either mild or no respiratory symptoms; and of the 6 that had nasal and pharyngeal swabs, all were negative for SARS-CoV-2 PCR. Only 4/7 had Covid-19 positive household contacts.

The implication is that children can harbour demonstrably invasive coronavirus with minimal symptoms and negative swabs. This has epidemiological as well as clinical significance. 

In conclusion, the presence of SARS-CoV-2 in the endothelium of dermal vessels in skin biopsies of children and adolescents with acute chilblains confirms that these lesions are a manifestation of COVID-19.  Their clinical and histopathological features are similar to those of chilblains of other aetiologies, and virus-induced vascular damage could explain their pathophysiology.  Our findings support the hypothesis that widespread endothelial infection by SARS-CoV-2 could have a role in the pathogenesis of severe forms of the disease. More studies are needed to understand the reasons why previously healthy children, adolescents and young adults present

Locatelli AG, Robustelli Test E, Vezzoli P, Carugno A, Moggio E, Consonni L, Gianatti A, Sena P. Histologic features of long-lasting chilblain‐like lesions in a pediatric COVID‐19 patient. Journal of the European Academy of Dermatology and Venereology.09 May 2020.  doi: 10.1111/jdv.16617. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jdv.16617

This retrospective single case report describes clinical and pathological signs of chilblain-like lesions whilst the patient was asymptomatic. He did not have any signs of autoimmune conditions including on histological examination. The lesions persisted for several weeks whilst he remained positive for SARS-CoV-2 on nasopharyngeal swab. The authors highlight young people with this sign could be carriers of the virus.

A 16-year-old male patient attended Papa Giovanni XXIII Hospital, Italy. His nasopharyngeal swab was positive for SARS-CoV-2. His mother was admitted to hospital for SARS-CoV-2 management following his presentation. 

Clinical features: Diarrhoea and dysgeusia were experienced 3 days prior to the onset of skin lesions described as “multiple asymptomatic erythematous oedematous partially eroded macules and plaques on dorsal aspects of the fingers”. A lesion was also noted on second toe. 

Radiology: None discussed. 

Bloods: “Routine bloods autoimmunity, cryoglobulins, viral serologies all negative or within normal limits”

Treatments: None 

Outcomes: Was treated on a hospital ward without supplemental oxygen until discharge.  

Other features of interest: Histopathological examination demonstrated oedema of the papillary dermis, superficial and deep lymphocytic infiltrate in the perivascular and strong peri-eccrine pattern. Images are provided.  

Recalcati, S., T. Barbagallo, L. A. Frasin, F. Prestinari, A. Cogliardi, M. C. Provero, E. Dainese, A. Vanzati and F. Fantini (2020). “Acral cutaneous lesions in the Time of COVID-19.” J Eur Acad Dermatol Venereol.

This pre-print Letter to the Editor reports on a series of unusual dermatological manifestations presenting to the Dermatologic Unit in Alessandro Manzoni Hospital, Italy in March and April 2020. The authors observed 14 cases, of which 11 were children with a mean age of 14.4 years and a range of 13-18 years. Of the 14 cases, 6 (43%) were male. 3 pairs of cases were siblings.

None of the cases had systemic symptoms (other than mild itch in 3 cases), there was no association with cold exposure, co-morbidities or drug intake, and there was no family history of COVID-19 related symptoms. 3 cases reported cough and fever 3 weeks prior to the onset of the lesions.

The authors believe that these dermatological findings are related to COVID-19 due to the rapid outbreak and clustering of these unusual skin lesions occurring at the same time as the COVID-19 outbreak. In support of this they report multiple similar cases being described from other areas affected by the pandemic. They hypothesise that the skin lesions may represent late manifestations of COVID-19 infection in young, healthy subjects, possibly due to an immunologic response targeting the cutaneous vessels. They accept that this hypothesis cannot be tested until a reliable serological test for antibody response to COVID-19 has been developed.

Clinical features: Acral eruption of erythemato-violaceous papules and macules, with possible bullous evolution or digital swelling. Lesions were found on the feet in 8 cases, hands in 4 cases, and on both sites in 2 cases. 2 children developed erythemato-papular targetoid lesions on the hands and elbows after a few days.

Histology: Lesions on fingers showed diffuse dense lymphoid infiltrate of the superficial and deep dermis, with a prevalent perivascular pattern and signs of endothelial activation. Targetoid lesions on elbows showed mild superficial perivascular dermatitis.

Bloods: Normal FBC, CRP, LDH and D-dimer. Serology was negative for EBV, CMV, Coxsackie and Parvovirus B19.

Outcomes: In all cases the lesions resolved without treatment after 2-4 weeks.

It is worth noting that this study is limited both by the small number of cases, but more particularly by the lack of evidence linking these skin lesions with a proven COVID-19 infection.

Piccolo, V., I. Neri, C. Filippeschi, T et al (2020). “Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients.” J Eur Acad Dermatol Venereol published online 24th April 2020 https://doi.org/10.1111/jdv.16526

This is a report of chilblain like lesions observed during the COVID-19 pandemic, collected through a survey issued to Italian dermatologists and Paediatricians. This is a preliminary report as data collection still ongoing. 

Importantly – very few patients in this cohort were tested for COVID-19 (11/63) and only 2 of these patients were positive. It is therefore difficult to extrapolate these findings to paediatric COVID-19 specifically, but is worth being aware of. 

63 patients have been reported on with a median age of 14 years (IQR 12 – 16yrs) with feet alone being bar far the most commonly affected area (85/7%) followed by feet and hands together (7%). In uploaded pictures from 54 patients, erythematous-oedematous lesions were most common (31/54) followed by blistering lesions (23/54) and pain and itch were common, although a quarter of lesions were “asymptomatic”. Median time of onset of rash to diagnosis was 10 days. The lesions were generally stable and no other cutaneous signs observed. GI symptoms were the most common co-existing (11.1%) with surprisingly low levels of respiratory symptoms (7.9%).

This is basically a description of a common skin manifestation which coincided with COVID-19, and looked like it could be infectious in origin. Few patients tested, and even fewer positive. An interesting series worth bearing in mind given increasing reports of skin manifestation of COVID-19.

Radiology Findings COVID-19

Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults [published online ahead of print, 2020 Mar 5]. Pediatr Pulmonol. 2020;10.1002/ppul.24718. doi:10.1002/ppul.24718

A case series of 20 paediatric patients with COVID-19 infection identified with COVID-19 NAT on pharyngeal swabs from Wuhan Children’s Hospital. It reviews the clinical information and co-infections.

Clinical features: two thirds had a clear contact history. Incubation 24hrs28 days of life. 13/20 had a cough, 12/20 had a fever. Bloods: 11/20 had (N) CRP, i.e. less than 3mg/L and 80% had PCT >0.05.

Radiology: On CT: Subpleural findings were seen in all 20 patients. 50% had bilateral findings, with a further 6/20 with unilateral findings. Consolidation with a halo in 50% of cases, considered as atypical signs in paediatric patien. Chloral hydrate was the primary sedative for CTs These were predominantly mild cases in the paediatric patients, with CXR adding little diagnostically. An early chest CT exam seemed to be necessary. 9/20 had coinfection, most commonly with mycoplasma (4/9) – although the ‘flu B,’flu A or RSV accounted for almost all of the remainder

Despite this, the physical chest symptoms were mild, with retraction in one case, and another case with cyanosis.

The average length of stay 12.9 days. Some patients were managed on the basis of their  CT alone. These are similar to those seen in adults.

Görkem, S. B. and B. Çetin (2020). “COVID-19 pneumonia in a Turkish child presenting with abdominal complaints and reversed halo sign on thorax CT.” Diagn Interv Radiol. June 5th 2020, DOI 10.5152/dir.2020.20361 

This is a case report of a 15 year old girl with Covid-19 from Turkey in an Epublished letter ahead of print with an early description of the “reversed halo sign”(RHS) on chest CT scan in. RHS is described  as a central ground glass opacity (due to septal alveolar inflammation) surrounded by denser granulomatous airspace consolidation in the shape of a crescent or ring. It was identified in adult Covid -19 patients in early studies from Wuhan. 

The patient presented with abdominal pain (epigastric tenderness). She had no respiratory symptoms and was apyrexial. Covid-19 was identified on nasopharyngeal swab. WCC 4.01×109, lymphocytes 1.92×109, CRP 1.6 mg/l rising to 10 mg/l after five days. Oxygen saturation remained above 95% in air.

Initial abdominal CT identified bilateral patchy alveolar infiltrates in the lower lobes and so an unenhanced low-dose thorax CT was performed. This identified multi focal RHS lesions within bilateral upper, middle and lower lobes. There were multiple multisegmental peripherally located alveolar infiltrations and scattered ground glass opacities.

The patient received hydroxychloroquine. Interestingly, she did not develop any respiratory symptoms, making an uneventful recovery and was discharged after 8 days.

RHS is a distinctive sign on chest CT. As well as occurring in pneumonia (including community acquired pneumonia) it can also be associated with fungal infections, immunosuppression, pneumocystis, TB, sarcoidosis, pulmonary neoplasms and pulmonary infarction. Therefore it can pose diagnostic challenges and management is guided by the clinical history. Although RHS is recognised in the adult Covid-19 literature this is a first report in a paediatric patient.

Denina, M., C. Scolfaro, E. Silvestro, G. Pruccoli, F. Mignone, M. Zoppo, U. Ramenghi and S. Garazzino (2020). “Lung Ultrasound in Children With COVID-19.” Pediatrics. 21. https://doi.org/10.1542/peds.2020-1157

Between March 18th and 26th 2020 8 children (age range 3 months to 10 years), 5 of whom were boys were admitted to Regina Margherita Children’s Hospital, Turin with Covid 19 respiratory tract infections. All 8 children had linear array chest ultrasound during routine medical examination. Although the number of patients analysed was small, the high concordance between radiologic and LUS findings suggested that ultrasound may be a reasonable method to detect lung abnormalities in children with COVID-19. The advantage of LUS was that the investigation could be done at the bedside, thus preventing transport of a potential infectious patient through a hospital

Li W, Cui H, Li K, Fang Y, Li S. Chest computed tomography in children with COVID-19 respiratory infection [published online ahead of print, 2020 Mar 11]. Pediatr Radiol. 2020;10.1007/s00247-020-04656-7. doi:10.1007/s00247-02004656-7

This study describes five children with confirmed COVID-19 who had CT chest scans in a large tertiary level hospital in China. Three of the five children had patchy ground-glass opacities on their CT scans but these changes were less severe than those seen in infected adults. The treatment is not detailed in the paper, so presented as published in this summary.

Case 1: 17 month old asymptomatic male. Bloods: CRP 9.4, WCC 9.2. Radiology: CT chest performed on day 4 showed patchy ground glass opacities. Repeat CT on day 9 after treatment had normalised (antiviral, anti-infective, immunoglobulin, interferon and Lianhua qingwen granules). No CXR.

Case 2: 10 month old asymptomatic female. Bloods: CRP 0.9, WCC 14.8. Radiology: Day 2 scan: normal. Not repeated. No CXR.

Case 3: 3 year old male with coryza, productive cough, sore throat and fever after 3 days. Bloods: CRP 0.7, WCC 15.0. Radiology: Day 9 CT showed patchy ground-glass opacities. Repeat CT on day 16 had normalised after treatment (antiviral, anti-infective, immunoglobulin). No CXR. 

Case 4: 4 year old asymptomatic male. Bloods: CRP 0.2, WCC 6.6. Radiology: Day 2 CT chest showed patchy ground-glass opacities. Repeat CT on day 7 had normalised after treatment (montelukast, immunoglobulin). No CXR.

Case 5: 6 year old asymptomatic male. Bloods: CRP 0.6, WCC 5.3. Radiology: 

Day 3 CT was normal. No CXR.

Liu H, Liu F, Li J, Zhang T, Wang D, Lan W. Clinical and CT Imaging Features of the COVID-19 Pneumonia: Focus on Pregnant Women and Children [published online ahead of print, 2020 Mar 11]. J Infect. 2020;S0163-4453(20)30118-3. doi:10.1016/j.jinf.2020.03.007

This study is a review of CT imaging findings in children and pregnant women in a hospital in the Hubei Province. Four children with confirmed COVID-19 infection were included in the study. The bottom line is that pulmonary CT changes in children were mild, with either focal ground glass opacification or focal consolidation. Although CT has been reported as a useful screening tool in adults with suspected COVID-19 infection, the CT changes of the four children were non-specific; the authors conclude that exposure history and clinical symptoms are more helpful for screening in swab-negative children than CT. 41 pregnant women with either laboratory-confirmed or clinically-diagnosed COVID-19 infection were included in the study. All pregnant women had mild courses of their COVID-19 illnesses. Six of the 16 laboratory-confirmed pregnant women and 10 of the 25 clinically diagnosed pregnant women delivered during the study period. There were no cases of vertically transmitted COVID-19 in the neonates born to these pregnant women.

Case 1: 5 year old female with fever, cough and fatigue. No lymphadenopathy. Bloods: low WCC with raised lymphocytes and decreased neutrophil ratio. Normal CRP. CT: normal. Follow-up CT 9 days later remained normal.

Case 2: 11 month old male with fever and cough. No lymphadenopathy Bloods: normal WCC with raised lymphocyte count and decreased neutrophil ratio. Normal CRP. CT chest: single consolidation without peripheral predominance (unlike reported findings in adults).

Case 3: 9 year old female with fever but no cough. No lymphadenopathy. Bloods: normal WCC, low lymphocytes and normal neutrophil ratio. Normal CRP. CT chest: single ground glass opacity without peripheral predominance (unlike reported findings in adults).

Case 4: 2 month old male with cough but no fever. No lymphadenopathy. This infant was coinfected with RSV. Bloods: normal WCC with normal lymphocytes and normal neutrophil ratio. CRP raised (does not say how high). CT chest: multiple focal consolidations and pleural effusion. This infant’s CT findings were more severe than the other three children, thought to be due to coinfection with RSV.

Cardiology Papers

Del Barba, P., D. Canarutto, E. Sala, G. Frontino, M. P. Guarneri, C. Camesasca, C. Baldoli, A. Esposito and G. Barera (2020). “COVID-19 cardiac involvement in a 38-day old infant.” Pediatr Pulmonol. June 18th 2020, https://doi.org/10.1002/ppul.24895

First (single) case report of an infant with biochemical and echocardiographic evidence of mild cardiac involvement due to SARS-CoV-2 infection.  The 38 day old male infant presented to hospital on 27/03/20.  Neither the centre nor the country is identified but is likely to be in Italy.  Pregnancy had been unremarkable.  No delivery details given.  Baby was formula fed.  Both mother and father were +ve for SARS-CoV-2.  He presented with a fever of 37.6oC and rhinitis but no respiratory distress and did not require oxygen therapy.  Nasal and nasopharygeal swabs were +ve for SARS-CoV-2.  Haemoglobin, lymphocyte count, CRP, ESR, electrolytes, liver transaminases, INR and PTT were normal.  Abnormal results: LDH “mildly increased”, platelet count 525,000/μl, procalcitonin 3.28ng/ml, troponin T 8.2ng/dl, creatine kinase-MB 9.8μg/L, D-dimer 13.3 μg/ml, pro-brain natriuretic hormone 208pg/ml, fibrinogen 1.28g/L.  CXR showed increased bronchovascular markings but no parenchymal changes (CT not done).  A resting heart rate of 140bpm and a transient peak rate of 200bpm were the only cardiac signs (serial ECGs and 24hr recording).  First echocardiogram showed no abnormalities but cardiac MR scan showed a “minimal amount” of pericardial effusion with no myocardial edema.  Follow up echo 3 days after the first confirmed a 2mm effusion.  A panel of other viruses linked to pulmonary and/or cardiac problems in infants was negative.  He required no treatment and was discharged after 14 days.  Swabs were -ve 21 and 22 days after presentation.

Selman Kesici, Hayrettin Hakan Aykan, Diclehan Orhan, Benan Bayrakci, Fulminant COVID-19-related myocarditis in an infant, European Heart Journal, June 12th 2020, ehaa515, https://doi.org/10.1093/eurheartj/ehaa515

Clinical Features: 2 year old previously healthy male in contact with Covid19, hospitalized with nausea, vomiting and lethargy. On Day 2 of admission deteriorated with Respiratory distress, filiform pulse and blood pressure was not measurable. There was hepatomegaly. Child was intubated in PICU, while preparing for ECMO went into cardiac arrest. 30 minutes of CPR was performed. During ECMO biopsy of myocardium was taken.

Radiology: Initial CXR – bilateral interstitial infiltrates. Day 2: CXR Cardiomegaly with pleural effusion. ECHO: Severe heart failure

Bloods: Initial bloods negative for inflammatory markers but Troponin was elevated 30 times normal on Day 2.

PCR for viruses were negative including RT PCR for Sars_COV_2

Myocardial Biopsy showed local inflammation, Positive for RT_PCR for COVID 19

Conclusion: Single case report showing the effect of COVID 19 causing heart failure secondary to Myocarditis without Kawasaki like Syndrome

Trogen, B., F. J. Gonzalez and G. F. Shust (2020). “COVID-19-Associated Myocarditis in an Adolescent.” The Pediatric Infectious Disease Journal. 03. June 3rd 2020, doi: 10.1097/INF.0000000000002788

This case report details the admission to PICU of a 17-year-old obese male (BMI 30kg/m2) with spondylolysis and a distant history of asthma (not requiring medication for > 5 yrs) who presented to a hospital in New York City during the third week of April with septic shock, after a week’s history of fever, GI symptoms and neck pain.

Clinical features:  7 day history of fever and neck pain and a 6 day history of diarrhoea and vomiting (non-bloody, non-bilious).  No neck stiffness, headache, photophobia or respiratory symptoms.  At presentation he was febrile, tachycardic and hypotensive (79/66 mmHg) with diffuse abdominal pain.  His cardiovascular status remained labile after initial fluid resuscitation and he was admitted to PICU.

Initial bloods:  Lymphocytes 0.9 x 103/μL, CRP 167 mg/L, ferritin 1275 ng/mL, D-dimer 1218 ng/mL, initial Troponin I level 2.97 ng/mL rising to 6.17 ng/mL 2 hrs later, brain natriuretic peptide 2124 pg/mL, sodium 128 mmol/L, creatinine 1.25 mg/dL, creatine kinase 761 U/L, LDH 346 U/L, INR 1.5, IL-6 28 pg/mL

Microbiology:  Nasopharyngeal swab RT-PCR SARS-CoV-2 positive.  Other respiratory and GI pathogen PCRs negative, including enterovirus, adenovirus, CMV, EBV, HHV-6, parvovirus B19.

Radiology:  Abdominal USS essentially normal.  CXR: low lung volumes, normal cardiothymic silhouette and mild, hazy ground glass opacities at the lower lobes bilaterally.  

ECG:  T-wave inversion particularly in inferior leads.

Cardiac imaging:  Initial transthoracic echocardiogram: LV ejection fraction mildly depressed with no obvious intracardiac clots or pericardial effusion.  Cardiac MRI: normal sized LV & RV, LVEF 40%, RVEF 39%, area of mid-wall late gadolinium enhancement at inferior LV-RV junction corresponding to area of increased T2 signal as well as an area of hypokinesia, consistent with myocarditis.  

Treatment in PICU:  Blood pressure normalised on day 1, but remained febrile and tachycardic until day 4.  Required 2 days of oxygen via NC.  Received anticoagulation, paracetamol/ibuprofen and 48 hrs of piperacillin/tazobactam until blood cultures reported negative.  No other anti-inflammatories or IVIg given.  Initially started on hydroxychloroquine which was stopped on day 3 when serial ECG demonstrated prolonged QTc interval not present initially.  Serial Troponin I and BNP levels normalised by discharge.

Outcome:  Discharged on day 5 with 2 week course of anticoagulation (apixaban).  Echocardiogram at follow-up one week after discharge demonstrated normal ejection fraction (59%) with qualitatively improved function.  However, tissue Doppler imaging signals of the mitral valve annulus were still abnormally diminished with low global longitudinal strain rate, consistent with residual myocardial dysfunction.  Repeat ECG showed persistent T-wave inversion in lead III.

The authors conclude with a discussion of the possible mechanisms of cardiac injury secondary to COVID-19, including viral entry via the ACE2 receptor causing direct damage to myocardiocytes, immune-mediated injury secondary to cytokine release or T-cell dysregulation, microvascular damage, endothelial shedding/dysfunction, hypoxia-mediated injury and abnormal coagulation, including DIC, increasing the risk of thrombosis and ischaemic events.

Ocular Manifestation

Valente, P., G. Iarossi, M. Federici, et al. Ocular manifestations and viral shedding in tears of pediatric patients with coronavirus disease 2019: a preliminary report. J aapos. June 10th 2020, https://doi.org/10.1016/j.jaapos.2020.05.002

27 paediatric patients were identified between 16/03/2020 – 15/04/2020, from Bambino Gesù Children’s Hospital, Rome, Italy. It was not clear how patients were identified/recruited. The mean age was 84 months (range=8 days to 210 months). 74% were male (n=20); 26% were female (n=7).

Clinical features present:
– Cough and/or dyspneoa = 15 patients (56%);
– Vomiting and/or diarrhoea = 8 patients (30%);
– Ocular manifestations consistent with viral conjunctivitis = 4 patients (15%);
In the abstract it states that “At admission, all patients showed ocular manifestations”, however there is no other reference to further information in the paper.

Radiology/bloods: N/a

Other investigations:
Nasopharyngeal swab to COVID-19 tested positive in all 27 patients.
Of the 4 patients with apparent viral conjunctivitis, 1 patient resulted positive for SARS-CoV-2 on RT-PCR from conjunctival swab.
Of the other patients (n=23), two more patients had positive findings for SARS-CoV-2 in their conjunctival swab without developing clinical signs of conjunctivitis.

Outcomes: 27 (100%) discharges. 

Other salient features: Some preliminary evidence to suggest that SARS-CoV-2 shedding is low in eye secretions/tears.

Testing/Viral Studies

M. A. De Ioris, A. Scarselli, M. L. Ciofi Degli Atti, et al. Dynamic viral SARS-CoV-2 RNA shedding in in children: preliminary data and clinical consideration of Italian regional center. J Pediatric Infect Dis Soc. May 23rd 2020, https://doi.org/10.1093/jpids/piaa065

This study at a paediatric hospital in Rome tracked SARS-CoV-2 shedding (nasopharyngeal, faecal, urinary and conjunctival) by following a cohort of 22 children during their hospital stay, collecting clinical and microbiological data. 

Study design:  The study ran from 16th March to 12th April in the COVID centre at Bambino Gesu Pediatric Hospital and collected data on 22 inpatients with an initial positive nasopharyngeal swab (either prior to admission or on admission).  RT-PCR for SARS-CoV-2 RNA on nasopharyngeal and conjunctival swabs and stool and urine samples were repeated every 2-3 days for each child while they were inpatients until they had two consecutive negative results in the absence of new symptoms.  Kaplan-Meier analysis was used to estimate the duration of symptoms and viral shedding for symptomatic patients: patients whose last swab/sample was still positive were censored at the date of the last swab.

Study population:  15/22 (68%) male, 7/22 (32%) female.  Median age 7 years (range 8 days to 17.5 years).  4/22 neonates (1/4 tested because mother positive and 3/4 tested because midwife positive).  2/22 comorbidity (Angelman syndrome, suspected genetic syndrome and autism).  13/22 patients were discharged before the end of the study period (median inpatient stay 7 days, range 3-15 days).  

Symptoms:  4/22 (18%) asymptomatic (including 2/4 neonates, the other 2/4 had low grade fever and poor feeding).  18 symptomatic patients: 15/18 (83%) fever, 10/18 (55%) respiratory symptoms, 7/18 (39%) diarrhoea and vomiting, 3/18 (17%) seizure.  Symptoms had resolved in all 18 before discharge from hospital.  Median duration of symptoms was 8 days (range 2-21 days).  15/22 had a positive stool sample at admission: of these 7/15 (47%) had respiratory symptoms and 3/15 (20%) had diarrhoea and vomiting.

Viral shedding:  At diagnosis: 22/22 (100%) had positive nasopharyngeal swab (by definition), 15/22 (68%) had positive stool sample, 1/22 (5%) had positive urine sample (re-test 2 and 5 days later was negative; another patient had initial negative urine test but repeat 3 days later was positive) and 2/22 (9%) had positive conjunctival swab (both were negative 2-3 days later).  A detailed table charting the dates of inpatient stay, onset and end of symptoms and positive/negative swabs/samples for each patient is supplied: the full screen of faecal, urinary and conjunctival sampling was performed at variable intervals after the initial positive nasopharyngeal swab (up to 5 days later in several cases).  For symptomatic patients:  (1) from date of symptom onset to negative nasopharyngeal swab: median 8 days (range 2-17 days) and (2) from date of symptom onset to negative stool sample: median 14 days (range 10-15 days).  Estimate of persistence of viral shedding at day 14 from symptom onset for nasopharyngeal swab 52% and for stool sample 31%.

The authors note the need to confirm the clinical relevance of faecal SARS-CoV-2 shedding in terms of the risk of transmission via the faeco-oral route.

Xu, Y, Li X. Zhu, B. et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nat Med (2020). https://doi.org/10.1038/s41591-020-0817-4

This study presents the results of widespread screening for COVID-19 in Guangzhou in China. 745 children were screened of which 10 were positive for COVID-19. Their ages ranged from 2 months to 15 years.

Clinical features: 6/10 had a fever over 38oC.  5/10 had a cough. 4/10 had a sore throat. 2/10 had rhinorrhoea and 2/10 had diarrhoea.

Radiography: 7/10 had coarse lung markings on CXR with no pneumonia, and 3/10 were normal. CT scans revealed ground glass or patchy opacities in 5/10.

Bloods: Basically normal in all cases

They made note that rectal swabs were frequently positive and that these swabs were positive for a longer duration than nasal swabs.  The authors suggest on this basis that faecal-oral transmission may be possible, however this is very uncertain and will require further research to elucidate.

Yuan, C., H. Zhu, Y. Yang, X. Cai, F. Xiang, H. Wu, C. Yao, Y. Xiang and H. Xiao (2020). “Viral loads in throat and anal swabs in children infected with SARS-CoV-2.” Emerg Microbes Infect: https://doi.org/10.1080/22221751.2020.1771219

This is a retrospective review of RT-PCR testing results of 2138 paediatric patients with suspected SARS-CoV-2 infection at Wuhan Children’s Hospital in Hubei, China, from 1 January to 18 March 2020.  All children were tested using throat swabs (TS); a subset of 212 were also tested using anal swabs (AS).  Changes in viral load in both throat and anal swabs were monitored in 13 patients.

Findings:  217/2138 (10%) confirmed cases on EITHER throat or anal swab.

78/217 confirmed cases had both types of swab: 24/78 (31%) positive for both TS & AS, 37/78 (47%) TS pos/AS neg, 17/78 (22%) TS neg/AS pos.  For those cases where the TS and AS results didn’t match (i.e. TS pos/AS neg or TS neg/AS pos):

Asymptomatic:  12/37 (32%) TS pos & 10/17 (59%) AS pos

GI symptoms:  7/37 (19%) TS pos & 6/17 (35%) AS pos

Cough:  16/37 (43%) TS pos & 4/17 (24%) AS pos

Fever:  20/37 (54%) TS pos & 5/17 (29%) AS pos

CT evidence of pneumonia:  25/37 (68%) TS pos & 10/17 (59%) AS pos

Time from positive to negative for PCR assay:  7 days for TS pos & 6 days for AS pos

The viral loads detected on throat swabs and anal swabs showed no difference.

Zhao, W., Y. Wang, Y. Tang, W. Zhao, Y. Fan, G. Liu, R. Chen, R. Song, W. Zhou, Y. Liu and F. Zhang (2020). “Characteristics of Children With Reactivation of SARS-CoV-2 Infection After Hospital Discharge.” Clin Pediatr,May 28th https://doi.org/10.1177%2F0009922820928057

In this study from Beijing, China, serial nasopharyngeal swabs were performed on children discharged between January 21st and April 18th 2020 following hospital admission with confirmed SARS-CoV-2 infection. Criteria for hospital discharge included clinical improvement and 2 negative RT-PCR tests for SARS-CoV-2 on consecutive nasopharyngeal swabs. Follow up swabs were performed fortnightly following discharge; the authors report on children with subsequent positive RT-PCR on follow up.

In total 14 children were followed, 7 of whom had a subsequent positive SARS-CoV-2 PCR result, none of whom had significant symptoms at the time (one with a temperature of 37.5). There were no significant clinical or laboratory differences between the group with subsequent positive tests compared with those who remained negative.

The authors refer to those who have subsequent positive SARS-CoV-2 PCR as having “reactivation” of infection. This is a misnomer as the persistent shedding of viral RNA has been well recognised in adult studies<https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25952>. This includes a large cohort of over 200 patients from Korea <https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030> with positive tests following negative PCR results, similar to the children in this study. Importantly no onward transmission from these “re-positive” cases was found amongst 790 contacts in the Korean cohort, suggesting the viral RNA detected in patients with prolonged shedding is not viable. Indeed in a recent in vitro study<https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa638/5842165> including 90 SARS-CoV-2 PCR positive samples, only samples taken within 8 days of symptoms onset were capable of infecting cells. This is in keeping with contact tracing data<https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765641> suggesting peak transmissibility occurs before and immediately after symptom onset with limited transmission beyond 5 days of symptom onset.

The likely explanation of the “reactivation” described here is prolonged shedding of non-viable viral RNA with an interim “false negative” samples prior to hospital discharge. Given the available data, it is unlikely that these “re-positive” discharged patients represent an infection risk to others

Xing Y, Ni W, Wu Q, et al. Prolonged presence of SARS-CoV-2 in feces of pediatric patients during the convalescent phase. doi:10.1101/2020.03.11.20033159

A pre-print, the information should be treated again with caution until it has undergone peer review.

This study of 3 paediatric patients with COVID-19 from Qingdao, China (aged 1.5, 5 and 6 years) all had fevers and none were severe. All children had elevated lymphocytes (>4.4 x 109/L) and 2 of 3 had abnormalities on chest CT (consolidation in one and ground glass changes in the other). The primary point made in the paper is that whilst respiratory swabs were negative within 2 weeks after children became afebrile, stool remained positive for over 4 weeks.

Pandey U, Yee R, Precit M, et al Pediatric COVID-19 in Southern California: clinical features and viral genetic diversity, medRXiv, June 2nd 2020, https://doi.org/10.1101/2020.05.28.20104539

A study of 35 children age range 18 days to 18.5 years (median12.5), 57% of whom were boys, seen over an 8 week period in Southern California. Patients were identified by nasopharyngeal swabs submitted to Los Angeles Children’s Hospital between 11 March 2020 and 11 May 2020. 37% were hospitalised with a median inpatient stay of 4 days. Symptoms were diverse with fever and cough being the most common, 1/3 were symptomless. Whole genome sequencing was undertaken on Covid-19 samples. There was an association between disease severity and viral load. Children < 5 years age had a higher viral load and all were symptomatic. There was limited variation in the viral genome though a calculated evolutionary rate was like other RNA viruses. No correlation was identified between disease severity and genetic variation.

Zachariah, P., K. C. Halabi, C. L. Johnson, S. Whitter, J. Sepulveda and D. A. Green (2020). “Symptomatic Infants have Higher Nasopharyngeal SARS-CoV-2 Viral Loads but Less Severe Disease than Older Children.” Clin Infect Dis, May 20th 2020, https://doi.org/10.1093/cid/ciaa608

This research letter details the viral loads of children with confirmed SARS-CoV-2 infection from Columbia University Irving Medical Centre in New York. All children admitted and discharged between March 14th to April 24th 2020 were included, timing of test relative to onset of symptoms, clinical severity along with viral load were compared between infants <1yo and children >1yo.
Of 57 patients with positive SARSCoV-2 PCR, 20 (35%) were under 1yo. Compared with older children, viral load was higher amongst infants <1yo (mean cycle threshold 21.05 vs 27.25, p<0.01 – where lower cycle threshold=greater viral load). Infants were tested earlier on average (2 vs 3.8 days from symptom onset) and fewer had severe disease compared with older children (5% vs 32.4%).

In this small hospital-based study symptomatic infants appear were found to have higher viral loads and milder disease compared with older children. This is in contrast to data from some adult studies where a higher viral load correlated with more severe illness.
Amongst several possible explanations for this observation are that:
– infants were more likely to be tested early in illness when viral load peaks<https://www.nature.com/articles/s41591-020-0869-5> – declining thereafter
– thresholds for hospital presentation may differ between infants and older children
– test performance and sample quality may differ between infants and older children
– there may possibly be differences in host biology according to age
Although some data suggest that higher SARS-CoV-2 viral load is associated with the presence of viable virus<https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa638/5842165> / in vitro infectivity, the exact implications of the findings here in terms of risk of transmission from infants compared with older children is unclear. Further studies examining SARS-CoV-2 viral load dynamics and correlation with clinical course in children are required to better understand potential variation between different age groups.

Haematology and Immunology Focus

Odièvre, M. H., C. de Marcellus, H. Ducou Le Pointe, S. Allali, A. S. Romain, J. Youn, J. Taytard, N. Nathan and H. Corvol (2020). “Dramatic improvement after Tocilizumab of a severe COVID-19 in a child with sickle cell disease and acute chest syndrome.” May 1st 2020, Am J Hematol. https://doi.org/10.1002/ajh.25855

The authors of this case study are based at two hospitals in Paris; in this correspondence they describe the treatment of a 16 year old girl with homozygous sickle cell disease (SCD) admitted to ICU with acute chest syndrome (ACS) and pulmonary emboli complicating COVID-19 pneumonia, in particular the use of Tocilizumab, a humanised anti-IL-6 monoclonal antibody (usual indications include use as immunosuppressant therapy in rheumatoid arthritis and giant cell arteritis in adults and juvenile idiopathic arthritis in children).

Course of SCD prior to admission:  The patient had a history of recurrent vaso-occlusive crises and abnormal transcranial dopplers between the ages of 5 and 11 years old, necessitating treatment with exchange transfusions.  At 11 years of age she was commenced on daily hydroxyurea with resolution of vaso-occlusive events.  She had no history of ACS or pulmonary hypertension; respiratory function and chest radiography were previously normal.

Presentation with COVID-19-19:  She presented with isolated fever, with nasophyaryngeal swabs subsequently confirmed as RT-PCR SARS-CoV-2 positive.  7 days later she developed acute chest pain associated with respiratory distress (SpO2 85%).

Radiology:  CT pulmonary angiogram (CTPA) showed bilateral pulmonary emboli and bilateral consolidation with right-sided halo sign.

Treatment in ICU:  Included non-invasive ventilation, anticoagulation and red cell exchange transfusion followed by simple transfusion (lowest Hb 64 g/L).  Based on recent experience in adult SCD patients with COVID-19 disease she also received a single infusion of Tocilizumab (8 mg/kg).  The authors report rapid clinical improvement after Tocilizumab with repeat CTPA 5 days later showing complete resolution of pulmonary emboli and consolidation on the right and decrease on the left.  She was discharged from hospital 11 days after admission to continue oral anticoagulation for 6 weeks.

Conclusions:  Inflammatory cytokines such as IL-6 and TNF-α are elevated in COVID-19.  COVID-19 pneumonia can cause ACS in SCD patients; there have been several recent reports of successful treatment using Tocilizumab.

Tsao HS, Chason HM, Fearon DM. Immune Thrombocytopenia (ITP) in a SARS-CoV-2 Positive Paediatric Patient. Pediatrics. 2020 May 1. doi: 10.1542/peds.2020-1419. Pre-publication version.   

A retrospective single case report was reported by Warren Alpert Medical School of Brown University, Rhode Island, USA, highlighting an association between SARS-CoV-2 and immune thrombocytopenia (ITP) in children. The patient was co-positive with rhinovirus and enterovirus, previously described in children managed for SARS-CoV-2. 

A 10-year-old female patient was admitted for management of ITP after presenting with a petechial rash. 3 weeks prior she experienced 2 days of symptoms: cough and fever, following exposure to the SARS-CoV-2 virus. She did not have a family history of haematological or autoimmune conditions, any medical problems or medications. 

A ‘respiratory panel’ was positive for rhinovirus and enterovirus and negative for coronavirus types 229E, HKU1, NL63, OC43. A Reverse transcriptase-polymerase chain reaction testing was positive for SARS-CoV-2. 

Clinical features: Initial illness (3 weeks prior to ED presentation): fever, non-productive cough

Presentation to ED: petechial rash spreading from the legs to chest and neck, oral wet purpura, ecchymoses in the popliteal regions and shins.  

Radiology: N/A

Bloods: At presentation: WCC 3.9 X 10^9/L (56% neutrophils, 38% lymphocytes) [Leukopenia without neutropenia or lymphopenia], haemoglobin 13.4 g/dL [normal], platelets 5 X 10^9/L [thrombocytopenia]. ANA borderline positive titers (1:40) in a speckled pattern which was considered not significant.

At 2 week follow up: WCC 6.1 X10^9/L [normal], Platelets 320 X 10^9/L [normal], ALT 56 IU/L [mildly raised], AST 28 IU/L [mildly raised].  

Treatments: Intravenous immunoglobulin, paracetamol, and antihistamine to manage ITP.  

Outcomes: Discharge from hospital after 1 day. Rash and oral lesions improved after 48 hours. Side effects were noted due to IVIG including headache, vomiting, abdominal pain. 

At 2 week follow up platelet count was maintained, white cell count normalised and a mild transaminitis was noted.  

Wu, H., H. Zhu, C. Yuan, C. Yao, W. Luo, X. Shen, J. Wang, J. Shao and Y. Xiang (2020). “Clinical and Immune Features of Hospitalized Pediatric Patients With Coronavirus Disease 2019 (COVID-19) in Wuhan, China.” JAMA Netw Open 3(6): e2010895. doi:10.1001/jamanetworkopen.2020.10895

In this retrospective case series from Wuhan, China, the clinical and immunological characteristics of children admitted to hospital with confirmed SARS-CoV-2 infection are examined. Details are provided for the 148 children with mild or moderate disease.

The median age was 84 months (IQR 18-123). Fever (40.5%) and cough (44.6%) and vomiting or diarrhoea (21.6%) were the most common symptoms. SARS-CoV-2 PCR became negative at a median of 7 days (IQR 4-11 days).
Lymphopenia was present in only 4.5% of patients; CD 4 lymphopenia in 1.9%. Elevation in CRP (32.4%) and procalcitonin (47.3% elevated; median 0.05 (IQR 0.04-0.08)) was observed in fewer than half of patients. Liver transaminases and LDH were significantly higher in moderate versus mild cases but the vast majority of levels fell within normal range.
Levels of inflammatory cytokines including IL2, IL6, TNG-a and IFN.y were largely normal; the authors note that one patient with severe disease had elevated IL-6 (3869 pg/mL). IL-10 was increased in 14%.
No deaths occurred amongst mild and moderate cases and all 148 patients were discharged.

In this large case series of children with mild or moderated SARS-CoV-2 infection, laboratory measures of inflammation were largely normal. Specifically the significant elevations in IL-6, D-dimer, and ferritin characteristic of severe COVID-19 in adults and also PIMS-TS / MIS-C in children were absent in these milder cases. The authors postulate that the relative preservation of CD4 T-cells and the higher levels of IL-10 compared with adults with severe COVID-19 may indicate these as important components of a protective immune response.
As yet our understanding of the drivers of variation in individual immune response to SARS-CoV-2 remains incomplete.

Venturini E,  Palmas G, Galli L. Severe neutropenia in infants with severe acute respiratory syndrome caused by the novel coronavirus 2019 infection. 2020 May 19. doi 10.1016/j.paeds 2020.04.051 [Epub ahead of print]

This case report from the Meyer Children University Hospital, Florence, published as a letter describes two infants with SARS-CoV-2 with transient severe neutropenia (<0.5 x109/l)

Clinical Features: The two female infants, aged 23 days and 39 days were admitted with mild respiratory symptoms and low grade fever. Nasopharyngeal swans were positive for Covid-19. There was no clinical deterioration in their condition during admission.

Radiology: not described

Treatment: not described.

Haematology: leukocytes and neutrophils normal on admission. At 5 days neutrophil counts fell to 0.244 x 109/lnand 0.482 x 109/l. Subsequently both improved.

Apart from age and gender there is no other demographic information nor any on treatments.

Although neutropenia is described in 6% of cases of Covid-19, severe neutropenia has not been described. In the report cases it was not associated with any change in clinical state. The authors suggest consideration of performing FBCs 5 to 7 days into the illness to identify neutropenia.

It requires further studies to see if these findings are replicated and whether they are clinically significant. The severity of the neutropenia could be age dependent reflecting bone marrow maturity as one patient was in the neonatal range and the other just beyond it. 

Chen, J., Z. Z. Zhang, Y. K. Chen, et al (2020). “The clinical and immunological features of pediatric COVID-19 patients in China.” Genes and Diseases. https://doi.org/10.1016/j.gendis.2020.03.008

This early study from Chongqing, China describes the features of 12 children diagnosed with COVID-19. All had a mild course of illness. CT imaging was abnormal in 10 of 12 with patchy ground glass opacity the most common finding. Lymphopenia was present in 2 children.
The authors also compare the “immune profile” (including lymphocyte counts, immunoglobulins, complement, CRP and IL6 levels) of the 12 children with a group of 20 adults patients. Aside from a lower CRP in children (mean 11.5 vs 23.3mg/L) and expected age-related differences in absolute lymphocyte numbers, there were no significant differences between the groups.

Other Interesting Clinical Papers

Xiong, X., G. T. Chua, S. Chi et al. A Comparison Between Chinese Children Infected with COVID-19 and with SARS. J Pediatr. June 18th 2020, https://dx.doi.org/10.1016%2Fj.jpeds.2020.06.041

In this study, 244 children with SARS-CoV-2 infection from Wuhan, China are compared to 44 children diagnosed with SARS (SARS-CoV-1) in in Hong Kong in 2003. 

The clinical details of this series of patients from Wuhan, previously described elsewhere, are compared with those of those of children with SARS-CoV-1. Overall children with SARS-CoV-2 were younger than those with SARS-CoV-1 (median age 82 montsh vs 160 months). Compared with SARS-CoV-1 patients, children with SARS CoV-2 were less likely to have symptoms (20.9% asymptomatic vs 0% of SARS-CoV-1), including fever (40.2% vs 97.7%), myalgia (37.6% vs 0.8%), and chills (32.6% vs 3.7%). 

Fewer children with SARS-CoV-2 required supplemental oxygen (4.7% vs 18.6%) and few in either cohort required mechanical ventilation (1.6% vs 2.3%). A single death occurred in a patient with SARS-CoV-2 (a 10 mo with intussusspection) and no cases of PIMS-TS / MIS-C were identified amongst the 244 SARS-CoV-2 infected children from Wuhan.

The most striking difference is the milder clinical illness and relative lack of symptoms in children with SARs-CoV-2 compared with those with SARS-CoV-1. The lack of asymptomatic infections in SARS-CoV-1 is also notable, similar to findings in adults. Whilst the role of asymptomatic patients in the spread of SARS-CoV-2 is unresolved, the milder clinical illness in the majority of patients along with the demonstrated earlier peak in viral shedding relative to symptom onset and resultant role of pre-symptomatic transmission are likely major reasons for the continuing widespread transmission of SARS-CoV-2, where the outbreak of SARS-CoV-1 in 2003 was more readily contained.

Li Y, Wang H, Wang F, Du H, Liu X, Chen P, Wang Y, Lu X, Comparison of Hospitalized Patients with pneumonia caused by COVID-19 and influenza A in children under 5 years, International Journal of Infectious Diseases (2020) https://doi.org/10.1016/j.ijid.2020.06.026

This study is from Wuhan children’s hospital, China. It is a retrospective one reviewing the clinical history, radiology and laboratory results of 57children under 5, with confirmed pneumonia on CT or radiography within 72 hours of admission, with COVID-19 diagnosed by detecting SARS-CoV-2 in throat swabs. The comparison group was 59 children aged under 5 who were admitted with influenza A pneumonia. Influenza A was diagnosed by direct immunofluorescence assay.

The 57 COVID-19 pneumonia children were consecutively admitted between 28th January and 11th March 2020; the 59 influenza A pneumonia children were consecutively admitted between 14th December 2019 and 30th February 2020(?).

The median age of the COVID-19 patients was 18.7+/- 16.7 months. The median age of the Influenza A patients was 21.8+/-16.7 months with no statistical difference. There was slightly higher proportion of males in each group 61.4% for COVID-19 vs 66.1% for the influenza A group with no statistical difference.

Clinical features: 31(54.4%) of the COVID-19 patients presented with fever compared to 50(84.7%) influenza A patients, P<0.001. 40(70.2%) of the COVID-19 patients presented with cough compared to 50(84.7%) in the influenza A group, p<0.001. Dyspnoea occurred in only 2(3.5%) COVID-19 patients and 5(8.5%) influenza A patients, p=NS. Gastrointestinal symptoms occurred in 8(14.1%) of the COVID-19 patients and 21(35.6%) of the influenza A patients, p=NS. Convulsions occurred in only 1 COVID-19 child and 3 influenza A children, p=NS. During hospitalization 1 COVID-19 child required supplementary oxygen and two required intensive care, compared to 7 influenza A children requiring supplementary oxygen and 4 intensive care, p=NS.

Radiology: CT chest imaging with ground glass appearance was more commonly found in COVID-19 pneumonia children 42.1% vs15% influenza A pneumonia children, p=0.03. Consolidation was more common in influenza A children (25%) compared to COVID-19 patients (5.2%), P = 0.02.

Haematology and Biochemistry

Haematology investigations showed COVID-19 patients had significantly lower levels of leukocytes and neutrophils but significantly higher lymphocyte levels compared with influenza A patients (7.87 vs. 9.89 ×109/L, P = 0.02; 2.43 vs. 5.16 ×109/L, P < 0.001; 4.58 vs. 3.56 ×109/L; P = 0.006.

Lower levels of C-reactive protein (CRP) were observed in COVID-19 patients than influenza A patients (3.7 vs. 15.1 mg/L, P = 0.001.

There were no significant routine biochemistry differences between the two groups except potassium which was significantly lower in the COVID-19 group.

Significantly lower levels of D-dimer and prothrombin time (PT) were found in COVID-19 patients than influenza A patients (0.34 vs. 1.94, P < 0.001; 10.8 vs. 11.2 mm/h, P = 0.014).

There were no deaths reported in this study.

Conclusion: The authors concluded that children under 5 with COVID-19 pneumonia compared to children with influenza A pneumonia showed milder clinical symptoms and a significantly increased lymphocytosis with a more prevalent ground glass CT chest appearance compared to influenza A pneumonia children under 5. There were no reported deaths or serious complications from COVID-19 in this study.

The study shows COVID-19 pneumonia is milder than influenza A pneumonia in a series children under 5. The influenza A patients were not typed and came from a different but overlapping time period during the winter months. Comorbidities were also not mentioned in either group.

Lu, Y., Y. Li, W. Deng, M. Liu, Y. He, L. Huang, M. Lv, J. Li and H. Du (2020). “Symptomatic Infection is Associated with Prolonged Duration of Viral Shedding in Mild Coronavirus Disease 2019: A Retrospective Study of 110 Children in Wuhan.” The Pediatric infectious disease journal. 05. doi: 10.1097/INF.0000000000002729

This retrospective study analysed demographic, clinical, laboratory, radiological and therapeutic data from the electronic medical records of 110 children hospitalised with “mild/ordinary” COVID-19 (classified as per the National Health Commission of People’s Republic of China National Recommendations for Diagnosis and Treatment of COVID-19, 7th edition) at Wuhan Children’s Hospital in Hubei, China between 30th January and 10th March 2020.  Inclusion criteria: throat or nasopharyngeal swabs RT-PCR SARS-CoV-2 positive and patient discharged from hospital after recovery (an initial cohort of 127 children was reduced to 110 after exclusion of 2 critical cases and 15 children in whom the onset of disease could not be accurately determined).

Study design:  Timings of onset of illness, most recent exposure (presumably to SARS-CoV-2-confirmed or symptomatic contacts, although this isn’t specified), diagnosis and discharge from hospital were recorded.  Patients were discharged only once they had two consecutive RT-PCR SARS-CoV-2 negative swab results (separated by at least 24 hours).  The authors calculated the duration of viral shedding for (a) symptomatic patients (81/110, 74%) as time from onset of illness to discharge and for (b) asymptomatic patients (29/110, 26%) as time from date of most recent exposure OR abnormal chest radiological imaging (reason for imaging not specified in these asymptomatic patients) to discharge.  This definition of duration of viral shedding, with starting point presumably in most cases a retrospective parent-reported start of symptoms or exposure to an infectious contact, and end point two negative swabs leading to discharge from hospital, makes interpreting the duration figures problematic.  Viral shedding in urine and faeces was not measured.

Clinical features:  Median age of the 110 children was 6 years (IQR 2-9); 59/110 male (54%), 51/110 female (46%).  Symptoms included: cough and dyspnoea 57/110 (52%), fever 56/110 (51%), GI (including diarrhoea, vomiting, poor feeding, anorexia, abdominal pain) 26/110 (24%), rhinorrhoea 10/110 (9%).

Radiology:  64/103 (62%) had unspecified chest imaging reported as demonstrating pneumonia (55/75 symptomatic (73%) and 9/28 asymptomatic (32%)).

Bloods:  Leucocytes < 4.0 x 109/L in 6/110 (5%) (all 6 were symptomatic).  Leucocytes > 10.5 x 109/L in 12/110 (11%) (9 symptomatic & 3 asymptomatic).  Lymphocyte ranges not specified.  Haemoglobin < 110 g/L in 13/110 (12%) (all 13 symptomatic).  Fibrinogen < 2.0 g/L in 34/90 (38%) (20 symptomatic & 14 asymptomatic).  Hs-CRP > 3.0 mg/L in 21/110 (19%) (18 symptomatic & 3 asymptomatic).  Procalcitonin > 0.05 ng/mL in 52/110 (47%) (43 symptomatic & 9 asymptomatic).  AST > 50.0 U/L in 19/110 (17%) (all 19 symptomatic).

Treatment:  None of the patients required oxygen therapy.  All of them received antiviral therapy, mostly commonly nebulised interferon-α.  According to the data table 22/110 received Chinese medicine therapy, although no details are given and it’s not clear if this was pre-hospitalisation.  Median duration of hospital stay was 10 days (IQR 8-13).

Conclusions:  The median duration of viral shedding using the definitions above was 15 days overall (IQR 11-20 days, range 5-37 days): 17 days (IQR 12-23) in symptomatic patients and 11 days (IQR 9-13) in asymptomatic patients.  Symptomatic infection, fever, pneumonia and lymphocyte counts < 2.0 x 109/L were reported to be associated with prolonged duration of shedding. 

Xiao, Z., X. Xie, W. Guo, Z. Luo, J. Liao, F. Wen, Q. Zhou, L. Han and T. Zheng (2020). “Examining the incubation period distributions of COVID-19 on Chinese patients with different travel histories.” Journal of infection in developing countries 14(4): 323-327. doi:10.3855/jidc.12718

Although all ages are affected by COVID-19, this paper makes it clear that the number of infected children is tiny compared to those in adults. The authors analyse incubation periods by age, finding that this increases in length in adults from aged 20 to 70+. The findings regarding children are more difficult to interpret due to small case numbers and therefore large confidence intervals, but it appears that 6 to 20 year olds may have a longer incubation period than young adults aged 20 to 60. The results for 0-5 year olds are fairly inconclusive. The authors then examine incubation in relation to travel history, finding that those who were affected by local community spread had longer incubation periods than those who had contracted the virus directly in Wuhan. They conclude that the virulence of the virus may decrease with intergenerational transmission, but that more work is needed.

Zhang, B., S. Liu, Y. Dong, L. Zhang, Q. Zhong, Y. Zou and S. Zhang (2020). “Positive rectal swabs in young patients recovered from coronavirus disease 2019 (COVID-19).” Journal of Infection April 23rd 2020, https://doi.org/10.1016/j.jinf.2020.04.023

In this case series from Dongguan, China, three normally fit & well children aged 14y, 13y and 10m were followed up after positive throat swab for SARS-CoV-2. All three had a subsequent negative throat swab within approximately 7 days, and fully recovered, however 7-9 days later all three had rectal swabs which were positive. These findings raise the question of whether apparently well COVID-19 patients continue to carry and possibly shed the virus. If this was found to be the case in larger and more comprehensive studies, there may be an argument for introduction of strategies to increase avoidance of transmission via the faecal-oral route.

Nathan, N., B. Prevost and H. Corvol (2020). “Atypical presentation of COVID-19 in young infants.” The Lancet 395(10235): 1481.  https://doi.org/10.1016/S0140-6736(20)30980-6

This correspondence in the Lancet describes the clinical features of 5 infants with COVID-19 who were admitted to a Paris hospital during the first week after imposed population quarantine in France (from 17th March 2020).  At this time at Trousseau Hospital, children needing admission with fever or respiratory symptoms (or both) were admitted to a dedicated SARS-CoV-2 infection unit: during this week 14 infants under the age of 3 months were admitted and of these 5 out of 14 were confirmed SARS-CoV-2 positive on nasopharyngeal swabs.

Age/gender of infants:  All 5 of these previously healthy infants with COVID-19 were boys; ages ranged from 1.6 to 2.7 months (median 2.1).  All of their parents had mild signs of viral infection (including fever, cough, rhinitis), which could have been indicative of undiagnosed COVID-19.

Clinical features at presentation:  5/5 fever (range 37.4 to 38.5 °C), 4/5 neurological signs (drowsiness/hypotonia/abnormal “moaning” cry), 4/5 mottled skin, 4/5 runny nose, 4/5 cough, 0/5 dyspnoea, 5/5 normal SpO2, 0/5 digestive symptoms.

Investigations:  FBC, CRP & procalcitonin largely unremarkable, with the exception of lymphopaenia in 2/5.  Lumbar punctures in 4/5 babies with abnormal neurology reported normal (including negative for RT-PCR SARS-CoV-2).  Chest X-rays performed in 4/5 essentially normal.

Outcomes:  All 5 showed rapid clinical improvement and received no drugs other than paracetamol.  Inpatient stays ranged from 1 to 3 days and duration of fever ranged from 1 to 5 days (max 39°C).  The infants were followed up for 2 weeks post-discharge with a daily phone call from a paediatrician using a standardised questionnaire.

Conclusion:  This encouraging report of a small cohort of SARS-CoV-2 positive infants under the age of 3 months presenting with fever showed initially concerning signs on admisson, but rapid recovery and minimal intervention needed for all 5 infants.

Wu, Q., Y. Xing, L. Shi, W. Li, Y. Gao, S. Pan, Y. Wang, W. Wang and Q. Xing (2020). “Co-infection and Other Clinical Characteristics of COVID-19 in Children.” Pediatrics. May 1st 2020, DOI: https://doi.org/10.1542/peds.2020-0961

This retrospective study from 2 hospitals in China examines the clinical and epidemiological characteristics of 74 children with confirmed SARS CoV-2 infection. Consistent with other studies, the majority of children experienced a mild course of illness with only one severe case requiring non-invasive ventilation. All recovered.

Cough was present in 32%, fever in 27% and 40% were asymptomatic at the time of testing. Lymphopenia was present in only 5% of cases. Abnormal CT imaging was observed in 50%, but only 12% showed typical changes of COVID-19.

Of those tested for other respiratory pathogens 19 of 34 had co-infection. Mycoplasma pneumoniae (16) and RSV (3) were the most common pathogens. It is not clear how these pathogens were identified. The significance of Mycoplasma in particular is not entirely clear as asymptomatic upper respiratory tract carriage<https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001444> in children is well recognised; similarly in interpreting serology, false positives<https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-0691.2004.00993.x> can be problematic.

For cases where exposure history was available 65/68 were household contacts of a confirmed adult case. There was no evidence of transmission from children to others.

This data is consistent with larger paediatrics studies demonstrating a milder course of COVID-19 in children compared with adults. Notably co-infection was not uncommon, illustrating that the presence of another respiratory pathogen should not preclude SARS-CoV-2 testing in children.

Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775

This is a paper from New York, USA, looking at the presenting characteristics, comorbidities, and outcomes of 5700 patients who were hospitalized with Covid-19. These were patients who were admitted to one of 12 Northwell Health acute care hospitals between 01/03/2020 and 04/04/2020. Clinical outcomes were monitored until 04/04/2020. All patients who were sufficiently medically ill to require hospital admission with confirmed severe acute respiratory syndrome coronavirus 2 infection by positive result on PCR testing of an NPA were included. The median age of patients was 63 years (IQR 52-75), 39.7% were female. 

There were only 59 patients under 10yo, and 15 patients between 10-20 years of age in this study.

The results below unless specified are for patients of all ages. 

At presentations, 30.7% of patients had a temperature of over 380C. 20% had oxygen saturations of less than 90%. 43.1% of patients were considered tachycardic with a heart rate of over 100. 

The majority of patients white cell count and differentials were within normal range. The mean white blood cell count was 7 (IQR 5.2-9.5). Neutrophil count 5.3 (IQR 3.7-7.7), however some patients were mildly lymphopenic, median 0.88 (IQR 0.6-1.2). 

Most patients had a low CRP, the mean result was 16 (IQR 6.4-26.9). Most patients had a raised ferritin, the mean result was 798 (IQR 411-1515), with 15-400 being considered normal range. Of note lactate dehydrogenase was tested in 70% of the patients and was significantly raised in most patients, the mean being 404 (IQR 300-551) with the normal considered to be 50-242.

A venous lactate was recorded in 44% of patients and all results were normal- <2. 

The most common comorbidities were hypertension (56.6%), obesity (41.7%) and diabetes (33.8%). 

At the study end point 2634 patients had been discharged or had died during hospitalisation. Of these 14.2% were treated in ICU, 12.2% of them received mechanical ventilation, and 21% of these patients died. At the end point of the study of those patients who had received mechanical ventilation 3.3% were discharged alive, 24.5% died, 72.2% were still in hospital. There were no deaths in the 34 patients under 18 age group out of those who had reached discharge end point. There were still 25 patients under 20 years hospitalised at the time of the paper. 

Of the patients who died, those with diabetes were more likely to have received mechanical ventilation or care in the ICU compared to those who did not have diabetes. Interestingly of those who died, those with hypertension were less likely to have received invasive mechanical ventilation than those without hypertension. 

As most patients were still in the hospital at the endo point of the study (53.8%) this biases rates toward including patients who died early in their hospital course. The researchers point out that as these patients complete their hospital course, reported mortality rates will decline. 

This study was slightly limited by the fact that the data was collected from the electronic heath record database and not the medical notes, from which a greater level of detail may have been established, however it was using this method that allowed for such a large number of patients to have been included and reviewed over a relatively short space of time. It is also limited by the fact that the study population only included patients from within the New York metropolitan area which may underrepresent some ethnic minorities. 

Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948

This is a cross-sectional study of children admitted to 46 PICUs in North America. 48 children were admitted during the collection period (March 14 to April 3 2020). All had confirmed COVID-19 infection on PCR from a nasal swab.

Most patients presented with respiratory symptoms, but there were other presentations – three with DKA, and one with vaso-occlusive crisis (sickle cell). 86% of these patients had at least one comorbidity. 69% were severely or critically ill on admission, and 25% needed vasoactive drugs. 81% of patients needed respiratory support that exceeded their baseline.
61% had a range of therapies, including Hydroxychloroquine, Azithromycin, Remdisivir, and Tocilizumab. These were used as single agents or in combination with other therapies.
The overall mortality rate was 4.2% (both patients who died had pre-existing comorbidities and developed multisystem organ failure). 32% were still hospitalised at the time of publication (including one patient still receiving ECMO). 65% had been discharged.

This study reinforces what is known about the decreased burden of disease from COVID-19 in children compared with adults. Critically ill children had a less severe course of illness and better hospital outcomes than in adults. Children commonly had medically complex comorbidities. Overall the mortality is much lower in children (4.2%) than has been reported in adults (50-62%)

Lazzerini, Marzia et al, Delayed access or provision of care in Italy resulting from fear of COVID-19, The Lancet Child & Adolescent Health, Volume 0, Issue 0, Published April 9th 2020, https://doi.org/10.1016/S2352-4642(20)30108-5

This is a report of case studies during the COVID-19 pandemic in Italy of children whose presentations were thought to have been delayed due to parental fears of coming to the hospital. They report from 5 hospitals between March 1st and March 27th 2020, where paediatric presentations were reduced between 73–88%.

During this period, in the week of March 23rd to 27th 12 children are identified whose parents reported avoiding accessing hospital due to concerns over SARS-CoV-2 infection . 6 of these were admitted to PICU and there were 4 deaths. The cases include 2 children with DKA, 2 with acute leukaemia, 2 children with cerebral palsy and complex needs, 1 with pneumonia and febrile convulsions, 1 with pyelonephritis, 1 with pyloric stenosis, 1 with a Wilm’s tumour, 1 with vomiting and hypoglycaemia and 1 with a congenital syndrome on dialysis.

This case series highlights the concerns of many paediatricians that more deaths will be seen in children from collateral damage born from the COVID-19 response, than will die of COVID-19. Delayed presentations is a major concern around the world currently, and whilst these cases certainly raise concerns, evidence is needed to ascertain the true presence and extent of this problem.

Preßler, J., S. Fill Malfertheiner, M. Kabesch, H. Buntrock-Döpke, S. Häusler, A. Ambrosch and S. Wellmann (2020). “Postnatal SARS-CoV-2 Infection and Immunological Reaction: A Prospective Family Cohort Study.” Pediatr Allergy Immunol. 9th June 2020, https://doi.org/10.1111/PAI.13302 

This letter to the editor in Pediatric Allergy and Immunology presents data on 61 deliveries where there had been varying degrees of unprotected parental contact with SARS-CoV-2-infected midwives, nurses and doctors during the first week (precontainment) of a COVID-19 outbreak affecting 36 staff members in a large maternity and perinatal centre in Bavaria, Germany.  Two previous papers in the same journal, published 22 April 2020 and 15 May 2020, have reported on containment strategies, symptoms, SARS-CoV-2 RT-PCR tests and antibody responses (IgG and IgA) in hospital staff during the outbreak.  The index case was a midwife returning from holiday in Ischgl, Austria on 8 March 2020, who became unwell during a nightshift on 9 March at Regensburg University Hospital obstetric clinic; the first positive SARS-CoV-2 RT-PCR test result was received on 15 March and at that point contact tracing, testing and containment measures were introduced.

Study design:  66 families were identified with an infant born at the clinic during the week of 9 to 15 March where parents had had unprotected contact with SARS-CoV-2-infected medical staff; of these, 61 families consented to a prospective cohort study involving serial symptom interview, serial SARS-CoV-2 RT-PCR screening in throat rinsing fluid (parents) and faeces (infants) and serum IgA and IgG antibody studies (parents and infants) 4-5 weeks post-partum.  Serum and breast milk were also tested using a different antibody assay to verify antibody responses.  The authors note in their paper of 15 May 2020 that IgM antibody testing would have been useful, but that validated and certified IgM tests were not available to them at that time.

Key neonatal findings:  The median gestational age at delivery was 39.3 weeks.  Infants in the study received skin-to-skin care, rooming-in and breastfeeding in line with the hospital’s usual practice.  The authors state that antepartum infections can be excluded and that any neonatal infections probably occurred via postnatal horizontal transmission in the family setting.  16/61 families reported parental symptoms consistent with COVID-19 within 2 weeks postpartum (one or both parents), although only 5/16 symptomatic families had COVID-19 confirmed based on RT-PCR and antibody evidence.  3 infants of these 5 symptomatic PCR-positive families developed non-specific signs of infection, including fever, dyspnoea and compromised circulation, at 5, 10 and 26 days old, and were admitted to NICU.  Details of treatment are not supplied, but symptoms resolved for all 3 within a few days.  Blood cultures and tests for non-SARS-CoV-2 viruses were negative.  2/3 symptomatic neonates had PCR positive faeces (one of these still had PCR positive faeces at 4-5 weeks) and 1 asymptomatic neonate also had PCR positive faeces at 4-5 weeks. None of the 3 SARS-CoV-2 PCR positive neonates nor the uninfected neonates had elevated or even borderline antibodies [note that there is some minor disparity between results summarised in the text and the detailed figure showing results in individual families].  Only one mother had IgG-positive breast milk (serum IgG also positive at 4-5 weeks, serum IgA negative, PCR positive at 1 week but not at 4-5 weeks, infant symptomatic at day 5 with negative faecal PCR at 1 week/4-5 weeks and negative serum IgG/IgA at 4-5 weeks).  

Small cohort <10 children and Single Case Reports

Ji L, Chao S, Want Y et al. Clinical features of pediatric patients with COVID-19: a report of two family cluster cases. World J Pediatr. 2020 Mar 16. doi: 10.1007/s12519-020-00356-2. [Epub ahead of print] https://dx.doi.org/10.1007/ s12519-020-00356-2

This is a review of two confirmed paediatric cases of COVID-19 (both from oropharyngeal swabs) from two family clusters with recent travel to Wuhan. One child presented with fever and the other with diarrhoea.

Case one: 15-year-old boy presenting with a one-day history of fever. Clinical features: Temperature 37.9oC, pharyngeal congestion. Normal lung auscultation. Laboratory findings: mildly elevated white cell count at 11.82 x109/L, predominantly neutrophils (67.3%) and 25.7% lymphocytes. His CRP was mildly elevated at 35 mg/L. Radiological findings: normal unenhanced CT chest. Outcome: Symptomatic treatment. Symptoms disappeared after two days. Family information: both parents also tested positive for SARSCoV2.

Case two: 9-year-old boy presented with mild diarrhoea but no cough and no fever. Normal examination. Laboratory findings: normal white cell count and normal CRP. Radiological findings: normal unenhanced CT chest. Outcome. Treated with oral probiotic and symptoms disappeared after 2 days. Family information: Family members had negative COVID-19 swabs but were symptomatic. His mother presented with fever and cough with bilateral peripheral ground glass opacifications on CT chest. The child’s father and two-year old sister had normal CT chests but had mild symptoms consistent with COVID-19: his father had a cough for four days and his twoyear-old sister had a transient two-day low-grade fever.

Liu W, Zhang Q, Chen J, et al. Detection of Covid-19 in Children in Early January 2020 in Wuhan, China. N Engl J Med 2020;:NEJMc2003717. doi:10.1056/ NEJMc2003717

This letter to the editor describes a case series from Tongji hospital in Wuhan, China, taken from a cohort of 366 hospitalized children between January 7th and 15th 2020. 6 children were PCR Positive for COVID-19. Of the 6 patients, age range 1-7 years. All had fever >39oC, cough and 4/6 had vomiting. All had lymphocytopenia, with 4/6 leukopenia and 3/6 with neutropenia. One child  required an ICU admission, receiving pooled donor IVIG. The median recovery time was  7.5 days. Authors surmise COVID-19 occurs in children with some moderate-severe episodes of illness.

Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection, The Lancet Infectious Diseases, 2020, https://doi. org/10.1016/S1473-3099(20)30114-6.

This case study looks at another family cluster of COVID-19 involving asymptomatic patients. It involved a 3yr old boy who was positive for SARS-CoV-2 despite having no symptoms, normal bloods and a normal CT.

Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang Z. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China. Published online February 14, 2020. doi:10.1001/jama.2020.2131

This is a case series of, from Dec 8 2019 to Feb 6 2020, from China of 9 infants – all of whom had been hospitalised. Clinical presentation: 4/9 fever, 2/9 mild URTI symptoms, 1/9 were asymptomatic. All had family members that were COVID-19 positive. There were no severe complications or ICU admissions.

Jiehao Cai, Jing Xu, Daojiong Lin et al, A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features, Clinical Infectious Diseases, ciaa198, https://doi.org/10.1093/cid/ciaa198

This retrospective study examines 10 children diagnosed with confirmed COVID-19 between 19th Jan and 3rd February 2020 at the Children’s hospital in Shanghai. The age range is from 3 months to 11 years. None had comorbidities. There were no severe cases.

Clinical features: The assumed incubation period (time from exposure to index case to developing symptoms) was between 2 – 10 days, but median (and mode) 7 days. With regard to symptoms, 7/10 had fever >38oC,  6/10 had a cough, 4/10 had a sore throat, 3/10 had nasal congestion, 2/10 had rhinorrhea and 2/10 were sneezing.

Radiology: The chest x-ray was normal in 6/10.  The rest had unilateral opacities.

Bloods: Lymphocyte counts were normal in 9/10, raised in one case. CRP ranged from 0.5mg/L to 35mg/L but was <10 for 7/10. Procalcitonin was normal (<0.25) in all children. 2 patients had a mild elevation of ALT (100U/L) or AST (142U/L and 51U/L)

Detection of SARS-CoV-2: Virus was found in NP/throat swabs in all patients, and the duration of shedding ranged from 6-22 days (Median 12 days). Stool shedding was prolonged, over 30 days in one patient. No urine was positive, and no serum positive.

Xu X-W, Wu X-X, Jiang X-G, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series BMJ 2020; 368 :m606

This study looks at a group of 62 patients with COVID-19 in a province outside of Wuhan (Hubei). 2 of these were children, aged 10 and 11. There is a lot of clinical data in the paper but it is not broken down by age, so we cannot make any inference on behalf of the paediatric patients.

Kai-Qian Kam, Chee Fu Yung, Lin Cui et al, A Well Infant with Coronavirus Disease 2019 (COVID-19) with High Viral Load, Clinical Infectious Diseases, ciaa201, https://doi.org/10.1093/cid/ciaa201

This was a case report of a single 6-month-old with a positive nasopharyngeal swab until D16 of admission to hospital. There had been household transmission. There was a positive NPA with rt-PCR on D1 of admission although the child was asymptomatic – daily swabs remained positive until D17. The child was febrile once during the course of admission although they remained asymptomatic. Blood and stool tests were positive on D2.  They had essentially normal investigations except for a neutropenia.

Cui Y, Tian M, Huang D, et al. A 55-Day-Old Female Infant infected with COVID 19: presenting with pneumonia, liver injury, and heart damage. J Infect Dis Published Online First: 17 March 2020. doi:10.1093/infdis/jiaa113

This is a case report of a 55 day old with SARS-CoV-2 who was admitted to hospital in China on February 2, 2020. She was treated with inhaled intereron-alpha-1b, amoxicillin, reduced glutathione, ursodeoxycholic acid, and traditional Chinese medicine lotus qingwen. The child was initially well, although her respiratory status worsened on day 2-6, and she required supplemental oxygen via nasal cannulae. Anal swabs on day 11 and 13 were positive on day 11-13 despite negative pharyngeal swabs.

Note is made in the title of this study that the infant sustained liver injury and heart damage. This is on the basis of marginally elevated liver tranaminases and cardiac troponin measurements, for which it is unclear why the tests were performed. There is no indication of any clinical compromise demonstrated. It should be noted that a significant proportion of the child’s care (including investigations) would not be considered standard practice in UK/US/Aus paediatric medicine.

Paret M, Lighter J, Pellett Madan R, Raabe VN, Shust GF, Ratner AJ. SARS-CoV-2 infection (COVID-19) in febrile infants without respiratory distress [published online ahead of print, 2020 Apr 17]. Clin Infect Dis. 2020;ciaa452. doi:10.1093/cid/ciaa452

This is a case series of two infants presenting with fever to a hospital in New York during on week in March 2020. Neither presented with respiratory symptoms, and both had Sars Cov2 infection confirmed without other aetiology despite febrile infant work ups. 

First; a 25-day old full-term male infant, presented with fever, irritability and facial rash. Parents had sore throat and subjective fever but had not sought medical attention for themselves. Full routine work up with CSF, blood, urine samples and routine respiratory PCR panel was taken. SARS CoV2 PCR positive on nasal swab.  Treated empirically until cultures negative at 48 hours, recovered well. 

Second; a 56-day old ex 35-week male infant, presents with fever only. He had no other symptoms, and no sick contacts. Bloods, urine and routine respiratory PCR panel was taken. Infant did not have lumbar puncture. SARS CoV2 PCR was positive on nasal swab. Treated empirically until cultures negative at 36 hours. 

Authors discuss the need to maintain high index of suspicion for SARS-CoV-2 infection in febrile infants during a community outbreak, and the importance of strict infection control measures in paediatric emergency department. 

Zhu, L., J. Wang, R. Huang, L. Liu, H. Zhao, C. Wu and C. Zhu (2020). “Clinical characteristics of a case series of children with coronavirus disease 2019.” Pediatr Pulmonol 8th April 2020 https://doi.org/10.1002/ppul.24767

This is a case series of ten paediatrics patients aged 1 – 17 years with confirmed Covid 19. These cases were retrospectively selected from 3 hospitals in Jiangsu, a coastal province approx 700 km east of Wuhan. Cases were collect from 24th January 2020 to 22nd February 2020. All cases were confirmed by RT-PCR anal or throat swabs. 70% of children presented with symptoms, and 30% were asymptomatic, but were screened due to contact with confirmed family member.

The most common symptoms on presentation were fever (40%), cough, (20%) and headache (20%). There was no report of whether children had underlying conditions. All children had a CT chest completed. Half of the cohort had CT changes. There were 2 cases of bilateral pneumonia, and 3 cases of unilateral pneumonia, 2 of which were in asymptomatic patients.  Bloods were unremarkable, one child aged 1 year had Lymphocytosis, all others had normal lymphocyte counts. CRP was not raised in any child. Only one patient in the cohort required oxygen, and there were no ICU admissions. Five children were treated with antiviral medication including lopinavir/ritonavir (n=4) interferon α‐2b (n = 4), and oseltamivir (n = 1). 

Of note, 5 children were still in hospital at the end of the case series. 

Canarutto, D., A. Priolo, G. Russo, M. Pitea, M. C. Vigone and G. Barera (2020). “COVID-19 infection in a paucisymptomatic infant: Raising the index of suspicion in epidemic settings.” Pediatr Pulmonol. https://doi.org/10.1002/ppul.24754

This early single case report from Milan, Italy describes an infant with a mild case of COVID-19 who recovered without need for intervention. His father, the implied household index, had an upper airway infection with conjunctivitis without confirmatory testing.
Patient: 32 day old boy, presented to hospital symptomatic
Clinical Features: Cough, fever, rhinitis
Radiology: CXR normal
Bloods: reactive lymphocytes on film, monocytosis (1400/L) and neutrpenia (900/uL), CRP normal
Outcomes: Resolution of fever by day 3 of hospitalisation, full recovery without need for supportive therapy. Breast feeding maintained.

Shen Q, Guo W, Guo T, Li J, He W, Ni S, Ouyang X, Liu J, Xie Y, Tan X, Zhou Z. Novel coronavirus infection in children outside of Wuhan, China. Pediatric pulmonology. 2020 Apr 7.p1-6 DOI: 10.1002/ppul.24762

This retrospective study examines the clinical characteristics of children admitted to Public Health centre of Changsha, Hunan, China. There were 9 children admitted during the study period 08/01/2019 and 19/02/2020 who tested positive for COVID-19. All had a confirmed contact case with COVID-19. Median age was 8 years, with a minimum age 1 year and oldest was 12 years. Children were predominantly female (6/9, 66%). There was no information provided about co-morbidities.   

Clinical features: 2/9 were asymptomatic, 1/9 had cough, 4/9 had fever, 1/9 had sore throat and 2/9 had diarrhoea. 

Radiology: 2 patients had chest CT that were described as ground glass opacities. No further information was provided about the indications.   

Bloods: 1/9 had lymphocytosis in whom other infectious causes were excluded. 1/9 had raised CRP, 4/9 raised ESR, 1/9 raised LDH, 2/9 had raised AST with 0/9 ALT abnormalities. All abnormalities were mild. 

Treatments: All (9/9) children were treated10/2.5 mg/kg lopinavir/ritonavir twice daily, orally. 5/9 children received 10 mg/kg azithromycin once a day. One child received meprednisone and immune globulin therapy for febrile convulsion. No additional information regarding treatments were provided.  

All children required oxygen therapy. None required intensive care or mechanical ventilation.

Outcomes: At the end of data collection 3/9 remained under hospital care and were positive for COVID-19. The remainder (6/9) were discharged from hospital. The time spent in hospital varied between 11 and 22 days (median 13.5 IQR 10.75-14 days). 

Other salient features: 6/9 children were RT-PCR negative at discharge. The time between initial contact and a negative test varied between 9 and 20 days (median 13.5 IQR 10.75-14 days).  

All averages were calculated by the reviewer from the data provided within the article. 

Han, Y. N., Z. W. Feng, L. N. Sun, X. X. Ren, H. Wang, Y. M. Xue, Y. Wang and Y. Fang (2020). “A comparative-descriptive analysis of clinical characteristics in 2019-Coronavirus-infected children and adults.” J Med Virol. 6th April 2020. https://doi.org/10.1002/jmv.25835

This retrospective study compares the clinical characteristics of 25 adults and 7 children with acute respiratory disease confirmed as COVID-19. Cases were retrospectively identified from patients admitted to Xian Eighth Hospital in Shaanxi, China, between 31st January and 16th February 2020. The mean age of the children was 1.3 years with a range of 2 months to 13 years, and 4 (57%) were male. None had any co-morbidities.

Clinical features: 5/7 (71%) children had cough, 3/7 (43%) had shortness of breath, 5/7 (71%) had fever, 1/7 (14%) had sore throat and 4/7 (57%) had diarrhoea and/or vomiting.

Radiology: 5/7 (71%) children had “positive findings suggestive of pneumonia” reported on CXR and/or CT. Examples of these findings were ground glass opacities and segmental consolidation in bilateral lung fields, particularly peripherally.

Bloods: No children had a low lymphocyte count (<0.8). Raised lymphocyte counts were not mentioned but raised WCC was reported in 2/7 (29%) children. 2/7 (29%) had a raised CRP (>10). 4/7 (57%) had a raised AST (>50) or ALT (>37). 5/7 (71%) had increased Brain Natriuretic Peptide (>125). 4/7 (57%) had a raised CK Isoenzyme (>30).

Outcomes: All 7 cases in children were classified as mild and recovered within 1-2 weeks. None of the children were admitted to intensive care and none died.

Comparison of clinical characteristics in adults and children: Children were more likely than adults to have diarrhoea and/or vomiting (57% vs. 8%, p=0.012). Adults more frequently had a reduced WCC, compared to a raised WCC in children, and raised CK isoenzyme was less common in adults.

Kamali Aghdam M, Jafari N, Eftekhari K. Novel coronavirus in a 15-day-old neonate with clinical signs of sepsis, a case report [published online ahead of print, 2020 Apr 1]. Infect Dis (Lond). 2020;1–3. doi:10.1080/23744235.2020.1747 634 Accessed from: https://www.tandfonline.com/doi/full/10.1080/23744235.2 020.1747634 on 4th April

This brief case report from Iran is of a 15 day old male from Mousavi Hospital in Zanjan, Iran. Date of admission was not available. Symptoms were fever and lethargy with his parents having fever and cough. He initially appeared tachycardic and febrile with sats of 93% on RA. He was given Vancomycin, Amikacin and Oseltamivir. SARS-CoV-2 was detected on RT-PCR. His parents were not tested as they did not meet the testing criteria at the time (hospitalisation). 

Radiology: Chest X-ray had nil findings

Bloods: WCC 6.7, Lymphocytes 36%, Neutrophils 42% and CRP 1 (normal). 

Comorbidities: There was an incidental finding of patent foramen ovale on Echo. 

Outcome: He had improvement by day 2 of admission and was cleared for discharge on day 6.

Su L, Ma X, Yu H, et al. The different clinical characteristics of coronavirus disease cases between children and their families in China – the character of children with COVID-19. Emerg Microbes Infect. 2020;9(1):707–713. doi:10.10 80/22221751.2020.1744483

This study from the Jinan Infectious Disease Hospital retrospectively reviewed cases of nucleic acid-positive SARS-CoV-2 patients between 24th January to 24th February 2020 (detected using the (ORF1ab/N) nucleic acid detection kit by Bio-germ, Shanghai, China). Nine children and members of their family totalling 14 adults were included. Note that two family members missed enrollment as they were at another hospital. Of the 9 children, 6 were female (66%). The age group ranged from 11 months to 9 years and 9 months old (mean age 4.5 years).  For eight of the nine children, there was history of their parents having travelled frequently, being in contact with someone from Wuhan or having worked or visited Wuhan.  Of note, five of the discharged children were readmitted to hospital because their stool showed positive results in SARS-CoV-2 PCR. 

Clinical Features (children): 3 of the 9 children had fever (33%) and one had cough (11.2%). Imaging (children): On chest x-ray and CT, two children had findings consistent with bronchitis (22.2%), one had bronchial pneumonia (11.1%) and a further one had pulmonary consolidation and ground glass opacity. From the two example images included,, findings appear to be bilateral but this was not specified in the body of the text. Bloods (children): 8 of 9 children (88.9%) had normal or decreased white blood cell counts. Six children (66.7%) had increased CK-MB. ALT, AST. All children had a normal CRP, PCT, ESR and IL-6. Clinical Features (adults): Of the 14 adults, 8 (57.1%) had fever, five had cough (35.7%), three had chest tightness or pain (21.4%), a further three had fatigue (21.4%) and one reported a sore throat (7.1%). Imaging (adults):  Ten (71.4%) had abnormal imaging mainly pulmonary consolidation, with 7 (50%) having nodular shadow and 7 (50%) having ground glass opacities. Bloods (adults): Four (28.6%) had reduced whice cell count with seven (50%) having lymphocytopaenia. 

Lou XX, Shi CX, Zhou CC, et al. Three children who recovered from novel coronavirus 2019 pneumonia. J Paediatr Child Health Published Online First: 22 March 2020. doi:10.1111/jpc.14871

This is a case series of 3 children diagnosed with COVID-19 and admitted in the Zhengzhou University Children’s hospital in Henan Province, China (dates not provided). They were 2 sisters aged 6 and 8yrs, and a 6m old infant. The children were all infected by a family member, although the family of the 6m infant had no link to Wuhan.

Clinical features: All 3 had a fever, 2 had nasal congestion and rhinitis alongside fatigue, diarrhoea, and headache. The 6yr old girl had a cough. 

Radiology: All 3 patients had CT scans with bilateral infiltrates

Bloods: Not reported

Outcomes: No children required intensive care/intubation or had any severe complications. All have been discharged. The 2 sisters were treated with nebulized interferon.

Mixed co-morbidities

Issitt R, Booth J, Bryant W, Spiridou A, Taylor A, DuPre P, Ramnarayan P, Hartley J, Borja MC, Moshal K, Dunn H. Coronavirus (COVID-19) infection in children at a specialist centre: outcome and implications of underlying high-risk comorbidities in a paediatric population. medRxiv. 2020 Jan 1. Doi https://doi.org/10.1101/2020.05.20.20107904

A retrospective cohort study published by Great Ormond Street Hospital (GOSH), London, UK suggested children who are defined as vulnerable in the COVID-19 pandemic era do not appear to be at significantly increased risk of being admitted to hospital with COVID-19. In addition, the vulnerable group have similar outcomes to those who are COVID-19 negative. However, the authors do identify children undergoing chemotherapy or radiotherapy are ‘over-represented’ in the vulnerable group.

Data was collected from the institution’s electronic health record system. The inclusion criteria were any patient admitted between 01/03/2020 and 15/05/2020 who was admitted with features suggestive of COVID-19 based on the attending clinician’s interpretation, of undefined grade, including fever, cough and “systemic symptoms”. Children were defined as COVID-19 positive by a positive PCR test for nucleic acid in respiratory or blood specimens performed at the referring or presenting hospital or a documented positive familial test. Patients were classified as vulnerable if they fulfilled the high risk shielded list from NHS digital or the institutions local policy that was not provided. Due to the nature of the specialist paediatric services the population of children were highly selected.

166 children fulfilled the criteria; 65 (38.7%) were COVID positive and 101 (60.8%) were negative. The average age for COVID positive group was 9 years [IQR 0.9-14] with 38 (58.5%) males. This compared to the COVID-19 negative group with an average age of 1 year [0.1-5.75], 58 (55.4%) male. The COVID-19 positive patients were significantly older (p<0.001). Differences in ethnicity frequency was statistically significant for Asian ethnicity: 12 (8.5%) COVID-19 positive compared to 6 (5.9%) in the COVID-19 negative group (p=0.02).

The number of vulnerable children who were COVID-19 positive totalled 31 (47.7%) compared to 73 who were COVID-19 negative (72.3%), demonstrating a lower number of vulnerable children were positive for COVID-19, (p=0.002).    

Clinical features: Breakdown of symptoms were not provided

Radiology: N/A

Bloods (For those COVID-19 positive):

ALT 41.5 U/L [IQR 29-74], Albumin 32 g/L [IQR 27-36], AntiDNAse 310U/mL [80.8-402], AntiStreptolysin O 285 IU/mL [134-384], AST 70 U/L [43-100], CRP 28 mg/L [10-74], CK 63.5 U/L [35-214], Creatinine 23 umol/L [14-46], D-dimer 1876 ug/L [1043-3618], Ferritin 788 ug/L [445-1863], Fibrinogen 3.65 g/L [2.4-4.8], Interleukin-6 50 pg/ml [50-152], Interleukin-10 50pg/mL, LDH 848 U/L [654-1136],  BNP 3550 pg/ml [626-6992], Lymphocytes 1.44 X10^9/L [0.64-2.49], Neutrophils 3.90X10^9/L [1.46-8.6], WBC 8X10^9/L [3.38-13.2], Troponin I 54 ng/L [13-157], Prothrombin time 12 seconds [11.3-13],  bilirubin 6 umol/L [3-10], Triglycerides 2.48 mmol/L [1.65-3.56].

The results highlight the difference in results between the COVID positive and negative groups but do not define further differences between vulnerable and non-vulnerable groups. These include a statistically higher average CRP (p=0.002, fibrinogen (p<0.001), albumin (p0.02) neutrophil (p<0.001) and white blood cell count (p<0.001) and a lower LDH (p=0.002),

Treatments: Patient were treated following national or speciality specific guidance. No further information was provided.

Outcomes: Mortality for those who were COVID-19 was 1 (1.5%) who was in the vulnerable group. Additional comments described the primary focus of treatment was aspiration pneumonia. This compared to 4 (4%) in the non-COVID-9 group, all of whom were in the vulnerable group. The difference in mortality rates was not statistically significant.

There was no difference in the proportion of vulnerable patients based on their COVID-19 status: 61% of vulnerable patients who were COVID-19 positive compared to 64.3% who were negative, (p = 0.84). Overall, comparing all patients, a significantly lower proportion of COVID-19 positive patients required mechanical ventilation (27.7%) than COVID-19 negative patients (57.4%), (p<0.001). The individual number of patients were not provided.

The average ICU length of stay for those with COVID-19 was 4 days [2.4-10.6]. For those in the vulnerable subgroup the average was 11 days [3.7-15.1]. The significance of the difference between the vulnerable and non-vulnerable group was not described. However, vulnerable non-COVID-19 patients had a 6 [2.8-12.2] day stay in ICU. The difference between vulnerable COVID-19 positive and negative groups demonstrated no significance (p=0.3). 

The average total hospital stay for vulnerable patients with COVID-19 was 16.2 days [3.8-20.8]. This compared to vulnerable COVID-19 negative patient were in hospital for 12.3 days [5.2-19.8]. The difference in duration was not significant (p=0.94). 

Other salient features: Breaking down conditions that comprises vulnerable children there was a significant increased number of children with cancer undergoing active chemotherapy or radiotherapy who were admitted to hospital with symptoms and COVID-19 positive status compared to with symptoms but COVID-19 negative [7 VS 3 (p=0.01)].  There was no statistical differences between the COVID-19 positive and negative categories with on the national transplant, transplant medication, haematological cancer, respiratory and rare genetic, metabolic and autoimmune conditions lists or local severe respiratory conditions, rare diseases immunosuppressive therapies and other potential factors lists.

Oncology

Gampel, B. Troullioud Lucas, AG. Broglie, T. et al. (2020 Jun 26). “COVID-19 disease in New York City pediatric hematology and oncology patients.” Pediatr Blood Cancer: e28420. June 26th 2020, https://doi.org/10.1002/pbc.28420

This retrospective observational study provides some insight into the impact of COVID-19 on haematology/oncology patients. There were some limitations in the data collection process as testing was performed for different reasons at the two different sites that are considered. However, we see that between 10/03/2020 – 06/04/2020,  19 out of 174 tested children (each of whom had underlying haematological/oncological disorder or were undergoing haematopoietic stem cell transplantation) tested positive for COVID-19. Of these, 11 required hospitalisation. Five required PICU and one sadly died.


Method of data collection: All patients 21 years old or younger who underwent clinical laboratory COVID‐19 testing at two New York haem/onc centres were included. All patients had underlying haematological/oncological disorder or were undergoing haematopoietic stem cell transplantation. Informed consent was waived.


The two centres tested differently: “MSK tested all symptomatic patients and screened all patients prior to admission, procedures requiring sedation, and planned myelosuppressive chemotherapy. NYP tested only those patients for whom a positive test would alter management, including those who were symptomatic, likely COVID‐19 exposed, or with planned disposition to a chronic care facility.”
Features specific to children:19 out of 174 tested positive. Of these: 68% had fever, 47% had cough and 37% had dyspnea. 11 patients required hospitalisation and 4 patients required supplemental oxygen. 2 patients required mechanical ventilation and a further 3 were also admitted to PICU (all male). 3 patients received ‘COVID-19-directed therapy’ (with hydroxychloroquine and azithromycin)
1 patient died (“a child with sickle cell disease without a significant history of prior complications. Although this patient demonstrated pulmonary disease, his death may have been preceded by an acute cardiac event. Autopsy was refused…”). The authors make note that 64% of COVID+ oncology patients experienced treatment delays, showing the harms to these patients may not come primarily from COVID-19 disease itself

Ferrari, A., M. Zecca, C. Rizzari, F. et al (2020). “Children with cancer in the time of COVID-19: An 8-week report from the six pediatric onco-hematology centers in Lombardia, Italy.” Pediatr Blood Cancer: e28410. 

This letter to the editor describes the findings of 6 paediatric haematology and oncology centres in Lombardy during the 8 weeks after the COVID-19 pandemic began in Italy. Between 20th February 2020 and 15th April 2020. 286 patients were tested for COVID-19 when accessing services at these centres: 74 were symptomatic, 25 had close contact with a diagnosed case and 187 were tested for screening purposes. Of these, 21 cases tested positive for COVID-19, with a median age of 6 years (range 1-17 years) and 48% were male.

Of the 21 cases 10 had leukaemia, 5 had soft tissue or bone sarcoma, 2 had lymphoma, two had hepatoblastoma, 1 had a CNS tumour and 1 had colon carcinoma. 15 patients were currently receiving treatment while 6 had completed treatment and were receiving follow up.

Clinical features: 1 patient (who had existing neurological respiratory impairment) developed aspiration pneumonia requiring respiratory support, and 1 developed atypical bilateral pneumonia with mild symptoms.

Outcomes: There were no deaths related to COVID-19 infection. Cancer treatment was modified in 10 cases (delaying chemotherapy, reducing drug doses and postponing surgery).

The authors observe that despite the overwhelming rate of COVID-19 in the general population in the region at the time, relatively few paediatric cancer patients were symptomatic, or tested positive for the virus, and that severe illness was rare. They suggest that these results may indicate that paediatric anti-cancer treatments could continue without major adjustments, especially as alterations may reduce their efficacy.

Of note, these centres experienced a reduction in newly diagnosed cancer cases to 55% of the expected rate, which may reflect delayed access to healthcare services.

Boulad F, Kamboj M, Bouvier N, Mauguen A, Kung AL. COVID-19 in Children With Cancer in New York City. JAMA Oncol. Published online May 13, 2020. doi:10.1001/jamaoncol.2020.2028

This research letter reports the results of SARS-CoV-2 screening of patients and caregivers from one of the largest paediatric cancer centres in the US (Memorial Sloan Kettering Cancer Center, New York) in a region with very high levels of community SARS-CoV-2 transmission.

From March 10th to April 12th 2020, inpatients and outpatients with either symptoms of or exposure to SARS-CoV-2 infection underwent RT-PCR testing. Asymptomatic patients were also tested prior to admission, deep sedation and or myelosuppressive chemotherapy, as were caregivers of children being admitted.

Overall 11% (20/178) of paediatric patients returned a positive SARS-CoV-2 result; including 29.3% in the symptomatic / exposed group and 2.5% in the asymptomatic group. In contrast 14.7% (10/76) of asymptomatic caregivers were positive. Despite close contact, 5 of the 10 children of caregivers with SARS-CoV-2 were uninfected.
Only 1 of the 20 paediatric patients required hospitalisation for COVID-19 symptoms, without need for critical care.

This data provides reassurance that children with cancer may not be more vulnerable to complications of SARS-CoV-2 infection compared to other children. The lack of specific clinical detail in this report limits the ability to draw more definitive conclusions regarding risk.
The lower rate of asymptomatic carriage in children relative to their caregivers provides further evidence that children, including paediatric cancer patients, may be less susceptible to SARS-CoV-2 infection compared with adults.
Clearly infection control strategies must consider the risk of nosocomial spread from infected caregivers as well as paediatric patients, particularly in areas with high levels of community transmission.

Cesaro, S., F. Compagno, D. Zama, L. Meneghello, N. Giurici, E. Soncini, D. Onofrillo, F. Mercolini, R. Mura, K. Perruccio, R. De Santis, A. Colombini, A. Barone, L. Sainati, V. Baretta and M. G. Petris (2020). “Screening for SARS-CoV-2 infection in pediatric oncology patients during the epidemic peak in Italy.” Pediatr Blood Cancer: e28466, https://doi.org/10.1002/pbc.28466

Observational study of nasopharyngeal presence of SARS-CoV-2 in a cohort of 282 paediatric oncology patient presenting for scheduled care at 14 specialist centres in Italy between 20/02/20 and 19/04/20.  Median age for oncology cases (n=247) was 7 years (range 0-17.9) and for stem cell transplant (SCT) patients (n=35) was 9.6 years (range 0.3-17.6). 10/334 swabs from the oncology group were +ve and 0/56 from the SCT group. Only 2/10 NPS +ve patients had any symptoms (both “mild fever”). Chemotherapy was paused for all NPS +ve patients until 2 clear swabs were obtained 24 hours apart.  No adverse outcomes were recorded up to the study end but follow up was only reported up to 30/04/20. This study demonstrates that paediatric oncology patients can remain asymtomatic whilst carrying SARS-CoV-2 in the nasopharynx, and recover spontaneously, without any apparent increased rate of adverse outcomes. Researchers raise the question of whether routine chemotherapy needs to be paused for asymptomatic NP carriage of SARS-CoV-2 but present no evidence for the safety of this course of action.

Flores V, Miranda R, Merino L, et al. SARS-CoV-2 infection in children with febrile neutropenia [published online ahead of print, 2020 Jun 12]. Ann Hematol. 2020;1-2. doi:10.1007/s00277-020-04115-1

This letter to Annals of Hematology offers a brief description of three children with ALL who presented with febrile illness and were found to be SARS-CoV2 PCR positive. The letter is of note as sadly one of the children died during this illness following cardiac arrest; the authors offer the paper to highlight the occurrence of SARS CoV2 in febrile neutropenic patients; however it prompts further analysis of those cases of severe infection in the context of immunosuppression.

The patients were identified at a centre in Mexico however the time period is not known. The three patients were aged 4yrs, 8yrs and 9yrs. All had ALL, two receiving consolidation chemotherapy and one on immunosuppression with mycophenolate and prednisolone. The latter patient had undergone HSCT for ALL, the time since HSCT was not provided, however this patient was admitted from the community suggesting she wasn’t in the immediate post-transplant period. All patients developed neutropenia either at time of fever or quickly following it and similarly evolved to have ‘respiratory symptoms’. All had negative blood cultures however results of other virology is not provided. Over-all pre-covid health status is not provided within the letter and this might be helpful in understanding the severity of symptoms in the patient who died.

The child who died was 8 years old and presented with febrile neutropenia, they were on mycophenolate and prednisolone following HSCT for ALL. The child quickly developed respiratory distress and required invasive mechanical ventilation; a heamodynamic deterioration led to cardiac arrest and resuscitation measures failed.

The distinguishing features of this child was her immunosuppression and history of HSCT, she was also more profoundly lymphopenic and thrombocytopenic. All other laboratory values were variable between all three patients. Further information on her overall cardiorespiratory status pre-SARS-CoV-2 would be helpful to understand her vulnerabilities and to guide management of children presenting with similar comorbidities in the future.

Sieni, E. Pegoraro, F. Casini, T. Tondo, A. Bortone, B. Moriondo, M. Azzari, C. Galli, L. Favre, C. Favourable outcome of Coronavirus‐19 in a 1‐year‐old girl with acute myeloid leukaemia and severe treatment‐induced immunosuppression. British Journal of Haematology. 2020 May 5. https://onlinelibrary.wiley.com/doi/epdf/10.1111/bjh.16781

This retrospective single case report discusses the progression and treatment of a child with high risk acute myeloid leukaemia having undertaken the third chemotherapy cycle of the induction phase following AIEOP LAM 2013 protocol.

13-month-old female patient attended routine clinic at Myers Hospital, Florence, Italy following completion of the chemotherapy. Routine investigations revealed a low white cell count, haemoglobin and platelet count which necessitated admission for transfusions. The need for admission was the initial reason for testing for SARS-CoV-2. RT-PCR was performed for nasal and pharyngeal swabs. Faecal PCR testing was also positive.   

Clinical features: Fever starting on day 3 (the combination of fever and low WCC suggested neutropenic sepsis), vomiting and diarrhoea with negative stool culture.

Radiology: CXR on day 3 showed bilateral reticular markings. A repeat prior to discharge demonstrated “no significant modification from baseline”.

Bloods: Day 0 showed low WCC (80/mmc), haemoglobin (7.9g/dL) and platelet (5000/mmc) count. The elevated CRP was highest at day 5 (7.2mg/dL) and normalised by day 10 (<0.5mg/dL). Additional laboratory investigations included LDH which was highest by day 13 (401  IU/L) and ferratin maximally raised on day 9 (3000 mg/mL). Immunoglobulins were low throughout the illness. On day 3 the results were: IgG 258 mg/dL, IgA 18.7 mg/dL, IgM 7 mg/dL. IL-1β, IL-6, IL-10, TNFα and cardiac enzymes were normal.

Blood microbiology was negative.

Additional  laboratory  investigations, including  cytokines  (IL-1β,  IL-6,  IL-10  and  TNFα)  and  cardiac  enzymes,  were  normal;  lactate dehydrogenase  slightly  increased  (up  to  401  IU/L  at  day  13),  whereas  ferritin  values  showed moderate elevation from day 9

Treatments: Treatment for neutropenic sepsis with piperacillin-tazobactam and fluconazole was commenced on day 3 due to fever. Hydroxychloroquine day 3-11. On day 4 lopinavir/ritonavir stopping day 12

Outcomes: Was treated on a hospital ward without supplemental oxygen until discharge. 

Other features of interest: There was a undetectable viral plasma load by day 16, however nasal swab for SARS-CoV-2  remained positive beyond discharge at day 26. There is no data to suggest a negative test to publication date. 

It is unclear if the low WCC, anaemia and thrombocytopenia requiring transfusion was due to the chemotherapy, underlying acute myeloid leukaemia or COVID-19 infection, however, on discharge these values had normalised and were maintained by day 26.   

Summary: This case describes a high-risk young patient with acute myeloid leukaemia undergoing chemotherapy presenting with febrile neutropenia. Whilst the symptoms were initially vague, subsequent investigations suggested the underlying cause was SARS-CoV-2. Early anti-viral treatments were commenced. Given the patient’s immunosuppression the authors discuss fears regarding seroconversion, viral dissemination and inflammatory responses which did not occur.  

Hrusak, O., T. Kalina, J. Wolf, A. et al. (2020). “Flash survey on severe acute respiratory syndrome coronavirus-2 infections in paediatric patients on anticancer treatment.” European Journal of Cancer 132: 11-16. https://doi.org/10.1016/j.ejca.2020.03.021

This is the report of a data from an international survey of paediatric haematology and oncology clinicians to assess the frequency and severity of SARS-CoV-2 infection amongst children with cancer. The survey, conducted from 16th-17th March 2020, had over 35 respondents from 25 countries. Of an estimated 10,000 patients at risk and over 200 tested, 9 children were positive for SARS-CoV-2. Clinical details are provided for 8 cases, 6 of whom had solid tumours and 2 with acute lymphoblastic leukaemia. 7 had mild or asymptomatic disease, 1 patient required low flow oxygen. Fever was the presenting symptom in 6 patients and one patient also had diarrhoea. All 7 patients with outcome data available made a full recovery.

The interpretation of these data is clearly limited by the study design as well as the relatively early stage of the pandemic during which the survey was conducted. Notwithstanding these limitations, the absence of severe COVID-19 cases in this report provides some early reassurance. More detailed clinical studies are needed to draw firm conclusions about the risk of severe disease in children receiving chemotherapy.

D’Antiga L. (2020), Coronaviruses and immunosuppressed patients. The facts during the third epidemic. Liver Transpl. Accepted Author Manuscript. doi:10.1002/lt.25756

This letter is from a liver transplant centre in Lombardy, Italy, reporting their experience of patients (including children) with immunosuppression and COVID-19. They have had 3 children post liver transplant test positive for SARS-CoV-2, and none have developed clinical pulmonary disease. They believe due to the widespread nature of infection that many other of their patients may also be infected, but not developed clinically apparent disease.

This provides the first official reports of vulnerable paediatric populations with COVID-19, which so far does not appear to be any more severe than the rest of the population in that age bracket. Further data is awaited.

Balduzzi, A, Brivio, E, and Rovelli, A et al, Lessons After the Early Management of the COVID-19 Outbreak in a Pediatric Transplant and Hemato-Oncology Center Embedded within a COVID-19 Dedicated Hospital in Lombardia, Italy. Estote Parati. (Be Ready.) (3/19/2020). Available at SSRN: https://ssrn. com/abstract=3559560 or https://dx.doi.org/10.2139/ssrn.3559560

This report from a paediatric haematology unit in Lombardia, Italy, includes the Italian experience of COVID-19 in children with malignancy so far. At their particular unit, they have had no children with malignancy test positive for COVID-19 (they admit this is dependent on testing criteria, requiring hospitalisation at their institute). They are aware of 5 cases of paediatric cancer patients who have had COVID-19 and have all suffered a mild course, with 3 managed at home and 2 in hospital.

This small case series provides further reassurance for at risk paediatric populations.

Cardiac disease

Lee, H., B. S. Mantell, M. E. Richmond, S. P. Law, W. A. Zuckerman, L. J. Addonizio, T. M. Lee and I. D. Lytrivi (2020). “Varying Presentations of COVID-19 in Young Heart Transplant Recipients: A Case Series.” Pediatr Transplant: e13780. https://doi.org/10.1111/petr.13780

This is a peer reviewed prepublication case report on the experience of Covid-19 among a population of young heart transplant patients from a tertiary centre, Columbia University Irving Medical Centre, New York.

Period Covered: first 3 months of the New York Covid pandemic

Hospital/Region Covered: the tertiary transplantation programme is one of the largest in the USA covering “hundreds” of patients.

Identification of Patients: 4 patients under the care of the hospital for heart transplantation are included. Case 1 was admitted after referral from secondary care with Covid symptoms and an oxygen requirement.. Cases 2 and 4 presented from home and case 3 was diagnosed during a planned admission for heart biopsy.

Age/Gender:  there is a wide age range: case 1 (F)15 years, case 2 (F)25 years, case3 (M)13 months, case 4(F) 29 months.

Comorbidities and immunosuppression: The authors highlight the questions of whether the comorbidities (including immunosuppression) associated with heart transplantation lead to worse outcomes with Covid infection? Also whether immunosuppression has a protective or aggravating effect on outcome and how regimes should be managed?

Two patients (1 and2)also had renal transplants. Case 2 had connective tissue disease (elevated IL-2).

All patients were on various combinations of immunosuppressants (1,2 and 3 on steroids).In only one case (1) was this withheld during infection because of neutropenia.

Clinical Features: 3 patients (1,2,3) had  symptoms of acute Covid-19 and were nasal/nasopharyngeal positive. Case 1 required supplemental oxygen but no other treatment for 3 days and was then discharged.Cases 2 and 3 did not require admission. Cough: 3/3. Fever: 3/3.Sore throat: 1/3. Abdominal pain: 1/3. All remained well on follow up.

Patient 4 is likely to have had Covid-19 4 weeks prior to admission (symptoms and family history). She presented with a probable post Covid anaemia and hepatitis. She had a rash (acral papular) She was negative on nasal and hepatic Covid assay. Her liver biopsy was consistent with viral hepatitis. Her Covid serology was positive and other viral hepatitis serology negative. She received a blood transfusion

Reported Imaging: CXR:1/4. Normal. Cardiac echo:2/4. No deterioration.

Laboratory: Case1: WCC low 1460/ul, neutropenia (800/ul). ?secondary to immunosuppression or Covid.  Elevated inflammatory markers: CRP, ferritin.  D-dimer, pro- BNP elevated.

Case 2:  no report. Case 3: normal FBC, CRP and LFTs.

Case 4: Hb 6.2 g/dl. Peak ALT elevated 1807 U/L. Peak AST 1070 U/L.

Comment: The centre maintains surveillance (telehealth) of most of it’s patients. Despite possible risk factors of comorbidities and immunosuppression only 4 cases presented. In the acute cases the illness was either mild (2,3) or moderate (1). This is the first report from a paediatric transplant centre and it will be necessary to examine the experience in other centres worldwide.

Case 4 developed hepatitis, anaemia and a rash 4 weeks after probable Covid infection. It is possible that this was Covid related.  Viral hepatitis has been reported in a child post liver transplant with acute Covid infection.

Respiratory disease

Poli, P., S. Timpano, M. Goffredo, R. Padoan and R. Badolato. “Asymptomatic case of Covid-19 in an infant with cystic fibrosis.” Journal of Cystic Fibrosis, April 14th 2020, https://doi.org/10.1016/j.jcf.2020.03.017

This is the first case report of confirmed SARS-CoV-2 infection in a child with cystic fibrosis. The 1 month-old, from Italy, was diagnosed with CF on newborn screening. SARS-CoV-2 infection was confirmed on nasopharyngeal swab PCR as part of contact tracing following exposure to COVID-19 through his grandfather.
The infant remained asymptomatic throughout follow up and did not require hospital admission.
This is one of a limited number of reports of SARS-CoV-2 infection in people with CF. A better understanding of the course of illness in this group will likely emerge with data from ongoing collaborative studies.

Inflammatory Bowel Disease

Turner D, Huang Y, Martín-de-Carpi J, et al. COVID-19 and Paediatric Inflammatory Bowel Diseases: Global Experience and Provisional Guidance (March 2020) from the Paediatric IBD Porto group of ESPGHAN [published online ahead of print, 2020 Mar 31]. J Pediatr Gastroenterol Nutr. 2020; doi:10.1097/MPG.0000000000002729

This article outlines the experience from Asia and Europe so far of children with inflammatory bowel disease given the COVID-19 pandemic. This is of particular interest because many of these children receive immunosuppression as part of their treatment, and so could be considered high risk for complications of the disease.

It appears to have been routine practice to suspend treatment for IBD during the outbreak of COVID-19, which resulted in a large number of relapses. No children with IBD contracted COVID-19 in China in the period covered by the survey.

In South Korea treatment for IBD was not suspended. They also have had no cases of COVID-19 in children with IBD.

In the PORTO IBD group of ESPGHAN (covering Europe, some centres in Canada and Israel) treatment was not suspended in 31/32 centres. 7 children with IBD, who were on immunosuppression, had COVID-19. They all suffered a mild illness with no flare of their IBD. There is an additional child case from an international IBD database identified who also experiences mild symptoms (no hospitalisation required).

This survey provides further reassurance that treatment with immunosuppression does not appear to significantly increase the risk of severe disease from COVID-19 in children.

Brenner, E. J., R. C. Ungaro, R. B. Gearry et al “Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry.” Gastroenterology https://doi.org/10.1053/j.gastro.2020.05.032

This is a pre-proof article and therefore has not yet undergone final editing and review.

This is an article from America (Carolina) aiming to characterise the clinical course of COVID-19 on patients with inflammatory bowel disease (IBD) and evaluate the association between demographics, clinical characteristics and immunosuppressant treatments of COVID-19 outcomes.

The authors created a surveillance database and healthcare providers were encouraged to voluntarily report all cases of Polymerase Chain Reaction (PCR)-confirmed COVID-19 patients with IBD.  A website was developed to enable international contributions. Contributors were asked to report cases a minimum of 7 days from symptom onset and after sufficient time had passed to observe disease course through to resolution of acute illness or death.

525 patients from 33 countries were reported. 7% had severe COVID-19, 31% were hospitalised, 3% of patients died.  The median age of patient was 41 years (from 5 to 90). The majority of patients had Crohns Disease (59.4%) and IBD disease activity was classed as remission in 58.9% of cases. The most common class of treatment was TNF antagonist therapy (43.4% of patients).

63.5% of patients had no comorbidities other than IBD. Most patients who died had other co-morbidities.  Only 3 paediatric patients (10% of paediatric cases) required hospitalization. After controlling for all other covariates use of systemic corticosteroids and ASA/sulfasalazine use were strongly associated with more serious outcomes after infection with COVID-19 but there was no significant association seen between TNF antagonist use and adverse outcomes.

The authors observed an age-standardized mortality ration of approximately 1.5-1.9 as compared to the general populations of China, Italy and the U.S.

They state it is reassuring that the most commonly used treatment- TNF antagonists- appears not to lead to increased adverse outcome for patients infected with COVID-19.

This study has strength in that it includes data from many countries although how comparable that data can be between countries is debatable. The authors did not look at dosing regimens or what was done in terms of continuing or postponing treatment which may well have varied from one country to another. There may also be some bias towards patients who were unwell enough to present to hospital, there may have been other patients who were infected but not unwell enough to require hospital treatment/testing  for COVID-19 who would not have been included in this study population.

Renal disease

Schwierzeck, V., J. C. Konig, J. Kuhn, A. Mellmann, C. L. Correa-Martinez, H. Omran, M. Konrad, T. Kaiser and S. Kampmeier (2020). “First reported nosocomial outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a pediatric dialysis unit.” Clin Infect Dis, https://doi.org/10.1093/cid/ciaa491

This paper presents the results of an outbreak investigation following a member of staff on a paediatric dialysis unit developing confirmed COVID-19. Detailed contact tracing was carried out and found that 48 cases in total were involved – this included 13 patients, 28 healthcare workers and seven ‘accompanying persons’. Of note, of the 3 traced who children tested positive for SARS-CoV-2, only one had symptoms; given these children’s high-risk status, their asymptomatic presentations are noteable. The paper discusses hygiene measures put in place to avoid further spread.

Transplant related disease

Lagana SM, De Michele S, Lee MJ, Emond JC, Griesemer AD, Tulin-Silver SA, Verna EC, Martinez M, Lefkowitch JH. COVID-19 Associated Hepatitis Complicating Recent Living Donor Liver Transplantation. Archives of Pathology & Laboratory Medicine. 2020 Apr 17. doi: 10.5858/arpa.2020-0186-SA.

This retrospective single case report examines the histopathological features of liver associated COVID-19 in a child admitted to Columbia University Medical Centre, USA. The female child, 6 months old, was admitted for a liver transplant for treatment of biliary atresia. COVID-19 was diagnosed in the donor on post-operative day 2 and confirmed in the patient day 4 post-operatively. The type of test used was not described.

Clinical features: Increased work of breathing requiring CPAP, fever and diarrhoea were developed on post-operative day 4.

Radiology: CXR on post-operative day 4 was described as “no significant changes compared to prior exam with only patchy areas of atelectasis in irregularly aerated lungs”. CXR on day 6 demonstrated “patchy lung opacities bilaterally, mildly increased in the right upper lobe and left lung base”.

Bloods: Deranged LFTs exacerbated from baseline on post-operative day 1: AST (maximum 908U/L from 163U/L), ALT (maximum 980U/L from 215U/L), GGT (maximum 473U/L from 174U/L), ALP (maximum 578U/L from 388U/L).

Treatments: Treated with hydroxychloroquine from day 4 post-operative. She required CPAP for an undefined time period. Undefined immunosuppressant treatment was provided for acute transplant rejection, however liver enzymes worsened when commenced.

Outcomes: Remains on a hospital ward without supplemental oxygen.

A liver biopsy was performed on post-operative day 7 demonstrating portal tract expansion through a mixed inflammatory infiltrate which consisted of lymphocytes, rare plasma cells, and interspersed eosinophils, lymphocytic cholangitis, reactive changes in the interlobular bile ducts and mild portal venulitis. These were interpreted as acute cellular rejection.

Other findings of moderate acute hepatitis including an “azonal pattern of clusters of apoptotic hepatocytes” and singly dispersed apoptotic hepatocytes. Other features of interest include large fragments of cytoplasmic debris described as “crumbling” hepatocytes, few mitotic figures, regions of Kupffer cell prominence with sinusoidal and central vein endotheliitis. The authors commented that the extent of hepatocyte apoptosis and large clusters were unusual and not a usual feature of acute cellular rejection (ACR). Central endotheliitis may also be a feature of COVID-19 hepatitis, with the presence of more Kupffer cells and less plasma cells than ACR.

Summary: COVID-19 hepatitis likely presents as a moderate acute hepatitis with prominent clusters of “crumbling” apoptotic hepatocytes. Other features may be lymphohistiocytic inflammation of sinusoidal and central vein endothelium, with the presence of more Kupffer and less plasma cells when compared to ACR.

Angeletti, A., A. Trivelli, A. Magnasco, S. Drovandi, F. Sanguineri, M. Santaniello, G. Ferrando, R. Forno, G. Cipresso, G. Tripodi, L. V. Riella, P. Cravedi and G. M. Ghiggeri (2020). “Risk of COVID-19 in young kidney transplant recipients. Results from a single-center observational study.” Clin Transplant. 2020 May 12. doi: 10.1111/ctr.13889. [Epub ahead of print]

Giannina Gaslini Children’s Hospital, Italy undertook this prospective observational study of patients, who received a kidney transplant between January 2010 and March 2020, with stable graft function and were taking chronic immunosuppressant therapy. They were interviewed weekly between 24th February and 12th April 2020 for 7 weeks, using a 12-point structure questionnaire contained in the appendix, to evaluate the health status of themselves and their cohabitants. The data for adults and children were combined presenting a median age of 20 (2-30) years. The demographics were reported as a combined total; 93 were male.

2 patients, an adult (information not included) and 1 girl aged 13, had co-habitants who were positive for SARS-CoV-2. The 13-year-old had a kidney transplant aged 9 years old. At the time of study, she was taking a combination of steroid, calcineurin inhibitor (CNI and mycophenolate mofetil (MMF) and had investigations including a white cell count and haemoglobin within normal limits.

She tested negative for SARS-CoV-2 using a nasopharyngeal swab (test not declared) and did not develop any symptoms in the subsequent 21 days, declared as the incubation period. Anti-SARS-CoV-2 antibodies were also negative at an undefined time point.

Clinical features: No patients developed any clinical symptoms.

Radiology: None discussed.

Bloods: None discussed for patients who were positive for SARS-CoV-2.

Treatments: None.

Outcomes: None.

Other salient features: The authors recommend avoiding altering the immunosuppressive therapy in young transplant recipients who do not have symptoms of SARS-CoV-2 including those who are exposed to positive close contact. Despite observing a relatively large population of kidney transplant recipients, a small number, 2 (1 child) were exposed to SARS-CoV-2, upon which has the conclusions are based.

Morand, A., B. Roquelaure, P. Colson, S. Amrane, E. Bosdure, D. Raoult, J. C. Lagier and A. Fabre (2020). “Child with liver transplant recovers from COVID-19 infection. A case report.” Archives de Pediatrie. https://doi.org/10.1016/j.arcped.2020.05.004

This a case report form France of a 2-and-a-half-year-old girl who recovered from COVID-19 infection, 5 months after a liver transplant; she had co-infection with Epstein-Barr virus (EBV).

The child had received a living donor transplant (father) as she had developed portal hypertension post Kasai portoentemrostoy performed at 53 days of age for biliary atresia.

She had been discharged home 20 days post procedure on tacrolimus immunosuppression therapy and had no immunization against EBV before transplantation.

On day 96 post transplant she was found to have primary EBV infection linked to the transplant- her father was EBV positive- but was asymptomatic of this.

The first developed rhinitis which developed into a fever, cough and tachypnoea.  In the few days before this her mother had been hospitalized with pneumonia and found to be COVID-19 positive on nasopharyngeal swab. On day three of the illness the child was referred to hospital where she was found to be positive for COVID-19 on NPA.

On admission she was tachypnoeic with no other signs of respiratory distress, her CRP was low (3). A chest CT showed focal alveolar condensation of the ligula and a stable mediastinal enlargement. Her liver function tests had deteriorated (GGT and AST). An US of the liver showed aggravation of the transplanted biliary tract stenosis and an elevated EBV blood viral load. She was managed symptomatically, and she did not receive any COVID-19 specific treatment.

She recovered from COVID-19 infection despite the high level of immunosuppression caused by her tacrolimus treatment.  NPA test samples became negative on day 11. The authors report they reduced the dose of tacrolimus but do not state at which point in the illness nor for how long. They do not state how long it took for her LFTs to return to previous levels nor if there were any consequences of the raised EBV viral load.

The authors suggest liver transplantation is not associated with COVID-19 symptom severity development even when there is high level immunosuppression on tacrolimus. Moreover COVID-19 and EBV co-infections do not seem to aggravate the clinical outcome.

It is difficult to draw conclusions based on one case study. Particularly as other studies have shown the severity of COVID-19 is increased when present with other co-morbidities. This particular patient, due to the nature of her original liver insult and the fact that she is a young patient, did not have other co-morbidities, this is often not the case for other patients who have required a liver transplantation.

 Other co-morbidities

Genovese, G., Colonna, C. and Marzano, A.V. (2020), Varicella‐like exanthem associated with COVID‐19 in an 8‐year‐old girl: A diagnostic clue?. Pediatr Dermatol. Accepted Author Manuscript. doi:10.1111/pde.14201

This single case report describes an 8 year old girl presenting on a hospital in Milan, Lombardy region, Italy, on 21 March 2020 with a painless, non-pruritic papulovesicular rash on the trunk developing 3 days after onset of a mild cough. The rash was predominantly papular with  some vesicles with crusting, similar in appearance to chickenpox. Limbs, face, genitalia and mucous membranes were spared. She developed a mild fever 5 days after the onset of the rash, and tested positive for SARS-CoV-2. She had bloods including FBC, renal function, liver function and CRP, all of which were normal with the exception of a mild thrombocytopenia with platelets of 105 x 109/L, which subsequently normalised. The rash lasted 7 days, by which time systemic symptoms had resolved. The young girl had a history of varicella infection a year previously.

The authors quote other case reports of cutaneous manifestations associated with COVID-19: petechial rash, widespread urticaria and varicella-like rash predominantly involving the trunk. Although unable to confirm that the rash was definitely associated with COVID-19, they feel it is likely given the child’s previous history of varicella infection and lack of pruritis to suggest the lesions were insect bites. They suggest papulovesicular eruptions be included in the spectrum of exanthems possibly associated with COVID-19.

Yung, C. F., Kam, K., Nadua, K. D. et al.  Novel coronavirus 2019 transmission risk in educational settings. Clinical Infectious Diseases. https://doi.org/10.1093/cid/ciaa794

A study of contact tracing of 3 clusters of confirmed COVID-19 within schools in Singapore. Only close contacts of the affected students were placed into quarantine for 14 days, not complete year groups/schools/or classes. Target health measures implemented included terminal cleaning and interventions to reduce mixing (examples were cancelling of extra-curricular activities and staggered break times). For 3rd incident in day care, the school was closed due to increasing cases amongst staff, and all students were tested regardless of exposure/symptoms.

Case 1: 12yr male in secondary school infected at home (sibling of case 2). Attended on day 1 of symptom and subsequently quarantined. 8 classmates developed compatible symptoms, all tested negative.

Case 2: 5yr male in primary school. Attended on day 1 of symptoms and quarantined. 34 classmates developed compatible symptoms, all tested negative.

Case 3: Multiple adult staff members in pre-school involved in cluster. 70% of all students tested, all negative.

These findings are consistent with the small number of other studies of transmission within a school setting so far, which have demonstrated infrequent transmission from children.

Heavey, L., G. Casey, C. Kelly, D. Kelly and G. McDarby (2020). “No evidence of secondary transmission of COVID-19 from children attending school in Ireland, 2020.” Euro Surveill 25(21). May 28th 2020, https://doi.org/10.2807/1560-7917.ES.2020.25.21.2000903

This is an epidemiological study describing cases of Covid-19 in Irish school setting in March 2020. Cases were identified by screening all cases of SARS-CoV-2 notified to public health departments in the Republic of Ireland, to identify children under the age of 18 years, and adults who had attended the school setting.

Six cases were identified, 3 school going children, and 3 adults (1 a teacher, and 2 who conducted educational session in a school). 5 out of 6 cases presented symptomatically with fever or cough, the final case was asymptomatic and screened due to a household cluster.  Contact-tracing records were reviewed to identify cases of secondary transmission.

A total of 1155 contact of these six cases were identified. In the school setting, among 924 child contacts and 101 adult contacts identified, there were no confirmed cases of COVID-19. The only documented transmission that occurred from this cohort was from an adult case to other adults working environment outside school.

In conclusion no case of onward transmission to other children or adults within the school occurred. In the case of children, no onward transmission was detected at all.  Furthermore, no onward transmission from the three identified adult cases to children was identified.

Limitations of the study, was only symptomatic contacts were tested, and so asymptomatic secondary cases were not captured. Also, in Ireland, when a case was identified, all children and staff within the school were excluded thus limiting the potential for further transmission within the school setting once a case was identified. All Irish schools closed on March 12th 2020 and remain closed.

Somekh, E., A. Gleyzer, E. Heller, M. Lopian, L. Kashani-Ligumski, S. Czeiger, Y. Schindler, J. B. Lessing and M. Stein (2020). “The Role of Children in the Dynamics of Intra Family Coronavirus 2019 Spread in Densely Populated Area.” Pediatr Infect Dis J. doi: 10.1097/INF.0000000000002783

This is a brief study of the transmission dynamics within households in Bnei Brak, an area of Isreal with high population density and high proportion of young people (almost 50% of its population are <18yrs). They assessed 13 family clusters and tested every member of their households by PCR, regardless of the presence or absence of symptoms. The index case was identified by date of onset of symptoms (this is standard practice but does leave open the possibility of mis-classifying the index case if they were truly asymptomatic).

The results were as follows; Excluding index cases, 58.3% of adults tested positive, 32.5% of children aged 5 – 17 tested positive, and 11.8% of children aged <5yrs tested positive. In 12/13 families the index case was an adult. The other case was a 14yr old male.

This evidence is consistent with almost all other household contact tracing studies which have demonstrated a significantly lower secondary attack rate in children compared to adults. A strength is the clear documentation that all household members were tested regardless of symptoms, and for clarity the index case was not included in the rates of infection making secondary AR better defined.

Qin-Long Jing, Ming-Jin Liu, Jun Yuan et al, Household secondary attack rate of COVID-19 and associated determinants in Guangzhou, China: a retrospective cohort study, The Lancet, June 17th 2020, https://doi.org/10.1016/S1473-3099(20)30471-0

This is study from Guangzhou, China documenting the attack rate amongst 1964 close contacts and 134 secondary or tertiary cases of 215 confirmed COVID-19 cases from January 7th to February 18th 2020.

There were 103 non-primary cases amongst 784 household contacts giving an attack rate of 13.1% overall. Notably children (<20yo) had a lower non-primary household attack rate of 5.2%.
In statistical transmission modelling to estimate true secondary attack rates, children (<20yo) had a lower odds of infection compared with adults >60yo (OR 0.23, 95% CI 0.11-0.46)

Only 10/215 (5%) of primary cases were children.

Although the criteria for testing contacts in this study are not entirely clear, the results suggests that children are less susceptible to SARS-CoV-2 infection compared with adults with similar exposure. This is in keeping with other reports from Asia (Zhang), Israel (Somekh) and the USA (Rosenberg).

Eli S Rosenberg, Elizabeth M Dufort, Debra S Blog et al. New York State Coronavirus 2019 Response Team, COVID-19 Testing, Epidemic Features, Hospital Outcomes, and Household Prevalence, New York State—March 2020, Clinical Infectious Diseases, ciaa549, https://doi.org/10.1093/cid/ciaa549

This epidemiological study examined the first 229 positive cases diagnosed in New York State outside of the city of New York from 2nd March to 12th March 2020 and described their outcomes. In addition, from the 5th March to the 17th March, they screened any household contacts of the positive patient. There was one ‘source’ patient under 5 years of age and 7 ‘source’ patients from 5 to <18 years of age. Household screening identified a further 42 children with COVID-19. No children <18 years of age required hospitalisation but it appears they only had complete data on 18/50 positive children.

Household contact with positive patients of any age found that likelihood of the contact being positive for SARS-CoV-2 increased with the contact’s age. Of the 25 children screened <5 years of age, 5 (20%) were positive and of the 131 screened age 5 to <18 years 37 (28.2%) were positive, compared to 16/29 (55%) of contacts aged 65+ years (p 0.002). This supports previous studies which shows a lower prevalence of SARS-CoV-2 infection in children <18 years. Unfortunately it does not described whether the household contacts of the 50 source children were positive for the infection too which could contribute to the discussion about whether children spread SARS-CoV-2 as effectively as adults and would require completion of the missing data and more in-depth analysis of the findings.

Zhang J, Litvinova M, Liang Y, et al, Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China, Science, 29th April 2020, DOI: 10.1126/science.abb8001

This fascinating study assesses contacts and infection risk in China (Wuhan and Shanghai) using 3 arms:

Surveys conducted within cities studying contacts between individuals, finding that during lockdown all contact except for those within households ceased – backing up evidence that about 90% of infections during this period occurred by household transmission

Most importantly for us – an age stratified model of susceptibility to acquiring infection was produced by assessing the data from the Hunan CDC, whereby every positive case found in Hunan had recent contacts placed under quarantine for 14 days and was tested for COVID-19. They estimated odds ratios for age groups to become infected, and performed statistical adjustment for clustering and correlation structures of contacts exposed t the same index case (generalized linear mixed model regression). Their finding was that susceptibility to infection increased with age, lowest in children 0-14 years (OR 0.34, 95% CI 0.24 – 0.49 – reference participants aged 15 – 64yrs).

Finally using the above data they estimated the effects of non-pharmceutical interventions on reducing spread of COVID-19. They found that closing schools was likely to significantly impact the R0 but not enoght to be a useful measure on its own. They describe social distancing as implemented in China, to be a sufficient measure to control COVID-19

This is the latest, and one of the most comprehensive of a number of studies to demonstrate significantly lower attack rate in children to adults, suggesting decreased susceptibility to infection.

Li, W., B. Zhang, J. Lu, S. Liu, Z. Chang, P. Cao, X. Liu, P. Zhang, Y. Ling, K. Tao and J. Chen (2020). “The characteristics of household transmission of COVID-19.” Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 17. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa450/5821281

This retrospective study calculated secondary attack rates of COVID-19 amongst 392 household contacts of 105 SARS-CoV-2 RT-PCR positive index cases hospitalised at Zaoyang First People’s Hospital (250 km from Wuhan) and Chibi People’s Hospital (150 km from Wuhan) between 1st January and 20th February 2020.

Study design:  Households were eligible for the study if the index case was the only member of the household with a clear history of exposure to Wuhan, its residents or high-risk sites in the 14 days before onset of illness (the assumption then being that the only exposure of household contacts to SARS-CoV-2 was via the index case).  Once index cases were confirmed, household contacts were quarantined for 14 days in local government sites and monitored daily, with at least 2 nasopharyngeal swabs (taken at the beginning and mid-point of quarantine).  Variables analysed retrospectively in this study (using medical notes and telephone interviews) included household size, age/gender/symptoms of index cases and household contacts, time between onset of illness of the index case and hospitalisation (range 0-11 days) and spouse/non-spouse relationships. 

Key paediatric findings:  100 of the 392 household contacts were under 18 years of age (median 6.5 yrs, IQR 4-11 yrs); of these, only 4 children became infected (all male, 1 aged 0-5 yrs, 3 aged 6-17 yrs).  This secondary attack rate of 4% for children compares with 21% for the adult household contacts (60 out of 292 infected) and 16% overall (64 out of 392).

Of interest:  14 of the 105 index cases self-quarantined within the home immediately after onset of symptoms before hospitalisation (wearing masks, eating and residing separately from the rest of the household); in these households there was a 0% secondary attack rate, versus 18% in those households where the index case didn’t self-quarantine before hospitalisation.  In households where the index case was afebrile, 13% of household contacts became infected, versus 19% where the index case had fever.  In households where the index case had no cough, approximately the same proportion of household contacts became infected as in households where the index case had a cough (17% vs 16%).  9 of the infected household contacts were asymptomatic (14%), but this figure isn’t broken down by age in the article.  [Note: there are some discrepancies between calculations in the text and data tables; data from tables used here.

This article provides further reassurance to the growing body of evidence of lower attack rates of COVID-19 in children as compared to adults, as well as a signal that symptomatic patients are higher risk of transmitting the virus than those who do not develop symptoms.

Wang, Z., W. Ma, X. Zheng, G. Wu and R. Zhang (2020). “Household Transmission of SARS-CoV-2.” The Journal of infection. 10. https://doi.org/10.1016/j.jinf.2020.03.040

This is a retrospective case series of 85 patients admitted to Union Hospital in Wuhan City, Hubei Province, China and their households, one household per index case.  The aim was to attempt to determine the transmission rate of SARS-CoV-2 among household members.

All patients were confirmed infected with SARS-CoV-2 with real-time reverse transcription polymerase chain reaction (RT-PCR) assays on throat swabs. The admission dates were February 13 and February 14, 2020. The city had been under lockdown measures since the 23rd of January.

The composition of these 85 households was 107 (45%) male adults, 115 (48%) female adults and 18 (7%) children.

64 (60%) of 107 male adults and 66 (58%) of 115 female adults were confirmed infected with SARS-CoV-2, only 2 (11%) of 18 children became positive. As a whole, there were totally 240 cases in these 85 households, with 132 (55%) of them were confirmed with SARS-CoV-2 infection and 57 (24%) cases were negative in RT-PCR assays.

The researchers found there was a secondary transmission rate of 30% and this increased to 50% for households with 2 contacts, they compared this to previous studies on other two coronavirus pneumonia epidemics which reported secondary transmission rates among household contacts of 5% for Middle East respiratory syndrome coronavirus (MERS-CoV) and 10.2% for severe acute respiratory syndrome coronavirus (SARS-CoV). The researchers concluded this demonstrated the need for stringent quarantining of household contacts.

This research did have some limitations. The researchers did not clarify what criteria they were using to guide testing nor did they quantify exactly how long they followed up household contacts for. It reproduces similar studies which have found significantly lower attack rates in children.

Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the primary source of household SARS-CoV-2 infections. medRxiv 2020;:2020.03.26.20044826. doi:10.1101/2020.03.26.20044826

A pre-print, the information should be treated with caution until it has undergone peer review.

This study includes a review of symptom frequency in children, but most interestingly examines available case series in the literature of family clusters of COVID-19 to determine what contribution is made of children to the chain of transmission. Clusters were taken from China, Singapore, the USA, South Korea and Vietnam, totalling 31 household transmission clusters. Of these cases, only 3 (9.7%) had a child as the index case. Considering a worst case scenario (whereby ALL infected children were the index case in their family and had been mislabelled as a secondary in some studies), still children would only account for 6/28 (21%) infection clusters. They compare this to the H5N1 epidemic where children were the index case in 54% of household clusters. This provides further evidence that children appear to have a fairly limited role in the transmission of COVID-19, which has implications for non-pharmaceutical interventions such as school closures.

Bi Q, Wu Y, Mei S, et al. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study, Lancet Infectious Disease, April 27th 2020, https://doi.org/10.1016/S1473-3099(20)30287-5

This was a fairly impressive study looking at contact tracing of 1286 contacts of 391 patients with COVID-19. Only 20 (5.1%) of the initial 391 cases were children, of which 2/3 were asymptomatic. They discovered a secondary attack rate of 15% for household contacts and 9.6% overall. The most important finding is that the rate of infection in children <10 years (7.4%) was similar to the population average (7.9%). The findings of this study suggested that children were becoming infected at a similar rate to adults but were much less likely to be asymptomatic. As no repeat testing was performed, it is unclear if these children were truly asymptomatic, or presymptomatic. Subsequent studies have consistently shown lower attack rates in children, and the reason for this discrepancy is unknown.

Pollán M, Pérez-Gómez B, Pastor-Barriuso R, et al. Prevalence of SARSCoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet 2020. https://doi.org/10.1016/ S0140-6736(20)31483-5

Introduction: Spain was one of the countries in Europe hit hardest by the Covid 19 pandemic. These are the first wave results from the Seroepidemiological Survey of SARS-CoV-2 Virus Infection in Spain (Encuesta Seroepidemiológica de la Infección por el Virus SARS-CoV-2 en España; ENE-COVID). This is an epidemiological study with an aim to estimate the sero-prevalence of Sars Cov2 in Spain through symptom checking, point of care antibody testing, and serology.

Methods: 35 883 households across Spain were selected through stratified two stage sampling and invited to take part. This is the result of the first wave of sampling which was conducted from April 27 to May 11, 2020. Participants within selected households answered a questionnaire on history of symptoms compatible with COVID-19 and risk factors. “Asymptomatic” was no symptoms, “paucisymptomatic” (1–2 symptoms without anosmia or ageusia), and symptomatic (anosmia or ageusia, or at least three symptoms among fever; chills; severe tiredness; sore throat; cough; shortness of breath; headache; or nausea, vomiting, or diarrhoea). Participants were contacted by phone and then invited to go to local primary care centre for testing or have a home visit. All participants were offered point-of-care antibody test (Orient Gene Biotech COVID-19 IgG/IgM Rapid Test Cassette; Zhejiang Orient GeneBiotech, Zhejiang, China, SARS-CoV-2 spike protein) and, if agreed, donated a blood sample for additional testing with a chemiluminescent microparticle immunoassay (SARS-CoV-2 IgG for use with ARCHITECT; Abbott Laboratories, Abbott Park, IL, USA, SARS-CoV-2 nucleoprotein). Sensitivity of the test was deemed any test positive (point of care/ serum), with specificity both tests positive. Of note Spain was under lockdown at the time of this study.

Results: Of 95 699 eligible individuals, 66 805 study participants took part, with 61 075 receiving point of care testing and 51 958 the immunoassay. Overall seroprevalence was 5.0% (CI 4.7–5.4) by the point-of-care test and 4.6% (CI 4.3–5.0) by immunoassay. In 7 provinces in the central part of Spain, including Madrid, seroprevalence was greater than 10% by both methods. Seroprevalence was similar for females and males. Seroprevalence was lower in the oldest age groups (≥85 years) compared with other adults. With regards occupation it was highest in health-care workers, 10.2% (7.9 – 13) than in other occupations these results were supported by the immunoassay.
In those who reported a contact with a confirmed case, seroprevalence was greater in those
who had a confirmed case in their household (range 31.4% to 37.4% between the two tests), in their workplace 9.9–10.6%, among their non-cohabitating family members and friends 13.2–13.7%, or among their caregivers and cleaning staff 12.4–13.5%

Symptoms: For both tests seroprevalence was highest in those with a confirmed Sars-CoV-2 PCR more than 14 days before testing (88·6–90·1%). Among those with a positive test, the proportion of individuals who reported anosmia or three or more symptoms compatible with COVID-19 was 49.1%
for the point-of-care test and 54. 2% for the immunoassay. In 32.7% (CI 30.2–35.4) of point-of-care test and 28.5% (CI 25.6–31.6) participants were asymptomatic.

Results in children: 11,422 children (<19 years) had a point of care test, with 6,527 also having an immunoassay. The proportion of paediatric participants having serology was lower than that of adults, though not unsurprising given the need for extra phlebotomy. Overall seroprevalence for those < 19 years was 3·4% (2·9–3·9) for point of care testing, and 6527 3·8% (3·2–4·6) for immunoassay.
Looking at specific age ranges for point-of-care test seroprevalence was < 1 year, 1.1% (0.3–3.5): 1- 4 years 2.1 %(1.3–3.4); 5 – 9 years 3.1% (2.2–4.2); 10-14 years 4.0% (3.1–5.0); and 15 – 19 years, 3.7% (2.9–4.8). The same pattern but slightly higher percentages were seen with immunoassay <1 year 0.0% (0.0–11.9); 1- 5 years 3.5% (1.7–6.8): 5 – 9 years 3.6% (2.3–5.7); 10 – 14 years 4.1% (3.1–5.5); and 15 – 19 years 3.8 (2.8–5.0). This paper did not give data on symptoms separately in age groups.

Conclusion: Population seroprevalence is lower than expected in areas of high endemic SARS-CoV-2, and is lowest in children. Close contact with people, particularly in the same household increases viral transmission. Over 30% of those with seroprevalence were asymptomatic. This highlights the importance of rapid identification and isolation with those with confirmed SARS-CoV-2, however isolation and separation for other household members may not be realistic in poorer or urban areas.

Gabriele Pagani, Federico Conti, Andrea Giacomelli et al, Seroprevalence of SARS-CoV-2 IgG significantly varies with age: results from a mass population screening (SARS-2-SCREEN-CdA). medRxiv June 24th 2020, https://doi.org/10.1101/2020.06.24.20138875

In this brief report of a SARS-CoV-2 serosurvey from Castiglione D’Adda in Italy, the results of a logistic regression model based on the random sampling of 509 subjects from the region (total population 4550) following the peak of transmission in the region are detailed. Prior to this serosurvey testing was limited to severely symptomatic cases.

The exact number of children included is not provided but the age related prevalence was significantly lower in children – 9.1% (0-5yo), 10.1% (5-10yo), 11.2% (10-15yo), 12.5% (15-20yo) – compared with overall seroprevalence of 22.6%.

The methodological details are limited in this report but the data are consistent with serosurvey data from elsewehere in Europe suggesting that children are less susceptible to SARS-CoV-2 infection compared with adults. 

Stringhini, S., A. Wisniak, G. Piumatti, et al. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study.” Lancet. June 11th 2020, https://doi.org/10.1016/S0140-6736(20)31304-0

Methods: This study takes a representative population sample from Geneva, Switzerland (already identified by a pre-existing health study) and invites them to attend blood tests looking for antibodies against the SARS-CoV-2 virus over time. The purpose is to monitor what proportion of the population are infected and see how it changes during the course of the pandemic (5 weeks in this study). Participants could only attend once, and were invited by email with a telephone follow up. The only exclusion criteria was living in a prison or care home. Antibodies were measured using a commercial assay (ELISA for S1 domain of spike protein IgG). They performed in house validation of the assay using a couple of techniques (the results of the immunofluorescence validation were factored in to the sensitivity analysis of the model used later in the study)

Analysis: The statistical analysis performed was a Bayesian regression which had a random effect for households and factored in age/sex as well as the test performance to extrapolate the sample results on to population estimates of seropositivity. They calculated the relative risk (RR) of age groups having been infected with age 20 – 49yrs as the reference group.

Results: 5492 people were invited and the final analysis included 2766 people (3426 of the rest were non-responders or awaiting an appointment). 455 children participated. Seropositivity in the population increased between weeks 1 and 2 (4.8% to 8.5%), with no statistically significant difference thereafter (final estimate 10.8%).

The most significant result is that of the children<10yrs in the study, only 1/115 children tested positive (although a further 8 had an equivocal result). This made the RR of infection for children <10yrs 0.32 (0.11 – 0.63) compared to adults aged 20 – 49yrs. There was no statistically significant difference between children aged 10 – 19 yrs (OR 0.86, 0.57–1.22). Another important factor was strong association between household contacts (unsurprisingly). This is important, as there were also lower rates of infection seen in the elderly (>65 yrs OR 0.5, 0.28–0.78) but only 3% of these participants had a positive household contact. Of the 123 children aged 5-9yrs, 17% of them had a positive household contact.

This study adds to a growing body of evidence that younger children (particularly those under 10yrs) may be less susceptible to acquiring infection than adults. The RR of 0.3 despite a relatively high proportion having positive household contacts is in contrast to the elderly, whose low infectivity rate may be explained by reduces exposure (additionally, a relatively high number of elderly will have been hospitalised or passed away from infection during the study, meaning they will not be counted in these statistics).

Considerations: Schools were closed for the duration of this study period which will have reduced community exposure of young children. In addition, almost all validation of antibody assays has been in adults so far. There were a notable number of equivocal results in the young children, but the significance of this is unclear. The results are however consistent with the largest seroprevalence study to date, from Spain.

Lavezzo, E., Franchin, E., Ciavarella, C. et al. Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo’. Nature (2020). https://doi.org/10.1038/s41586-020-2488-1

This paper outlines the strategy of a small town in Italy which immediately shutdown for 14 days following their first death from COVID-19 on Feb 21st 2020. They subsequently screened 86% of the population for SARS-CoV-2 using nasopharyngeal swabs, then screened again 2 weeks later (71.5% of the population).

At the start of the lockdown 2.6% (95% CI 2.1 – 3.3%) of the population tested positive, but 0 of 217 children aged 0 – 10 tested positive (0%), and only 3/250 aged 11 – 20 (1.2%) tested positive. By the end of the lockdown, 0/157 (0%) children aged 0 – 10 tested positive, and 2/210 (1%) children aged 11- 20 tested positive. Many of the children aged 0 -10 lived with infected individuals. They also noted >40% of people who tested positive were asymptomatic. They note a significant number of infections appeared to have come from asymptomatic individuals during contact tracing. They also note these asymptomatic individuals never developed symptoms, and had similar viral loads to symptomatic patients (as determined by the cycle threshold from RT-PCR). It should be noted the definition of symptoms was restricted to ECDC definitions of COVID-19 related symptoms, and given the wide variation of non-classic symptoms which have been described (rashes, malaise, joint aches, rhinorroea, GI symptoms etc), this likely significantly undercounts the number of patients who truly developed symptoms.

This study has relatively small numbers, but again appears to provide evidence for several important features of paediatric infection: primarily that children appear significantly less likely to become infected than adults. It presents evidence for asymptomatic transmission, and against the theory of viral load correlation with symptom burden.

Gudbjartsson DF, Helgason A, Jonsson H, Magnusson OT, Melsted P, Norddahl GL, et al. Spread of SARS-CoV-2 in the Icelandic Population. N Engl J Med, Published April 14th 2020, doi:10.1056/NEJMoa2006100.

This study describes the entry and spread of SARS-CoV-2 through Iceland. Importantly, this is the first epidemiological report to include SARS-CoV-2 screening of the general population and likely represents the most complete national epidemiological data published to date.

Study design: This report includes all confirmed SARS-CoV-2 infections in Iceland identified through either: targeted testing (January 31st to March 31st 2020) – 9199 predominantly symptomatic patients with travel to a high risk country or contact with a confirmed case; population screening (March 13th to April 1st 2020) – 13080 volunteers screened from the general population (without high-risk travel or contact with a confirmed case). Most patients in the population screening cohort were asymptomatic, with a minority with predominantly mild URTI symptoms. A subsequent period of random population screening from April 1st-4th excluded children.

SARS-CoV-2 real-time PCR was performed on combined oropharyngeal and nasopharyngeal samples. All confirmed cases were isolated and close contacts placed in quarantine for 14 days.

Key paediatric findings – there is comparative data provided on the 1412 children <10 years of age tested: of 564 children <10 years old tested in the targeted testing cohort, 6.7% (38) were positive – compared with 13.7% of persons >10 years old; of 848 children <10 years old tested in the population screening cohort, 0% (0) were positive – compared with 0.8% of persons >10 years old.

Details on severity of infection, hospitalisation rates and age specific symptom profiles are not included.

Discussion: The first SARS-CoV-2 infection in Iceland was confirmed on 28th February 2020. The dynamics of new cases has transitioned from imported infections initially to ongoing community spread. To date just over 0.5% of the population have had confirmed infection. Whilst physical distancing measures have been put into place including limiting gatherings to a maximum of 20 people, elementary schools have remained open. Iceland has amongst the highest national rates of SARS-CoV-2 testing per capita, with 6% of the population tested as described here. As a result this report provides the most accurate and complete national epidemiological data published to date.

The lower rate of positive tests in childen <10 year olds adds support the hypothesis that children are less susceptible to SARS-CoV-2 infection compared to adults. Similarly the lack of positive tests amongst >800 children screened goes against the theory that the low reported rates of COVID-19 in children are due to a large number of undocumented/asymptomatic paediatric cases. This finding, particularly, has important implications in decision-making around patient flow and isolation in general paediatric care, suggesting that routine testing and isolation of asymptomatic children may be of low yield in similar settings. Clearly a single PCR screening test at one time point has an insufficient negative predictive value to exclude infection. As such, serological studies will be important in providing a clearer picture of the extent of SARS-CoV-2 infection in children.

Conclusion: Children under 10 yo appear to be less likely to develop SARSCoV-2 infection compared with people >10 yo. In settings with moderate levels of SARS-CoV-2 infection (0.5% population with confirmed infection in this setting), screening of asymptomatic children without overseas travel or contact with a known case is of very low yield.

Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. ePub: 6 April 2020. DOI: https://dx.doi. org/10.15585/mmwr.mm6914e4

This is the first USA CDC report of COVID-19 looking specifically at children, examining confirmed cases nationally between FEbruary 12th and April 2nd. Due to the extremely disparate nature of public health reporting in the USA, the data quality and availability for this report is highly variable. There is no information as to the basis on which tests were performed, whether for presentation to hospital, symptomology or due to contact tracing. This cohort is therefore likely extremely heterogeneous. Of the nearly 150,000 confirmed cases in the US at this time, 2,572 (1.7%) were in children. New York City had 33% of paediatric cases. The median age was 11y and males account for 57%. Nearly 33% of cases were in children aged 15 – 17yrs, 15% in children <1y, 11% in children ages 1 – 4y and 15% in children 5 – 9y. 91% of cases had xposure to a known COVID-19 case.

Data on signs/symptoms was only available for 11% of cases. Fever, cough OR shortness of breath were present in 73% of cases, with fever in 56%, cough in 54%, shortness of breath in 13%, rhinorrhoea 7.2%, sore throat 24%, vomiting 11% and diarrhoea 13%. They have not reported on “asymptomatic” cases due to incomplete reporting on symptoms.CU admission was documented for 2% of cases. Hospitalisation was most common in infants (62%), with little difference between other age groups in regards to hospitalisation or ICU admission. From low numbers infants id not appear significantly more likely to be admitted to ICU. Underlying conditions were present in 23% of cases, most commonly respiratory (such as asthma), followed by cardiac conditions and immunosuppression. There are 3 deaths reported, but review is ongoing to determine whether COVID-19 was the cause. This patchy data from the US is useful as it closely resembles data from Chinese cohorts of children in regards to low frequency of severity and adverse outcomes. It confirms available data suggesting lower frequency of common symptoms in children as compared to adults.

Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics 2020:e20200702. doi:10.1542/peds.2020-0702

This landmark paper is a retrospective epidemiological study of 2143 pediatric patients with suspected or confirmed COVID-19 (Jan 16 – Feb 8 2020) from in and around Hubei province in China. Confirmed cases were diagnosed by PCR of NPA or blood or genetic sequencing from the respiratory tract or blood highly homologous with SARS-CoV-2. To be a suspected case you needed to be high risk (based on community exposure) with any 2 of: fever, respiratory symptoms or diarrhoea/vomiting; normal or lower white cell count +/- raised CRP; abnormal CXR. If you were medium/low risk for community exposure, you could still be a suspected case if you met any 2 of the above criteria and had other respiratory viruses excluded. Patients were classed according to severity.

There were 731 (34.1%) laboratory-confirmed and 1412 (65.9%) suspected cases. The median age was 7 years. There were 94 (4.4%) asymptomatic, 1091 (50.9%) mild and 831 (38.8%) moderate, accounting for 94.1% of all cases. Of note, the youngest patients (under 1yr) had the highest proportion of severe and critical illness (10.6%). However, this group also had the highest proportion of “suspected” disease (293/379) – of which we do not know how many had an infection with RSV, HPMV or Flu. This was peak bronchiolitis season. There was one death in a 14yr old boy, for which there are no clinical details available. The highest proportion of asymptomatic cases was in the 6-10yr olds (31.9%), for whom there was no recorded critical illness. Critical illness was uncommon in general (0.6% of all cases). The median time from illness onset to diagnosis was 2 days. Chest imaging was emphasized in delineating the severity (CXR and CT). There are also  some interesting epidemiology graphs which essentially map to the well-described adult prevalence of disease and demonstrate Hubei as the epicentre.

This large cohort study provides reassuring data about the severity of illness of COVID-19 in children. There is an indication that younger infants may be most likely to be affected most severely, however, this cohort is highly likely to contain children with normal, severe, winter viral infections such as bronchiolitis. Critical illness was extremely rare.

Felstein, L.R. et al (2020) Multisystem Inflammatory Syndrome in U.S. Children and Adolescents, NEJM. epub 29 June 2020, DOI:10.1056/NEJMoa2021680.

This retrospective and prospective multi-centre cohort study from 53 participating hospitals in 26 states looked at 234 patients under 21 years of age that met criteria for multi system inflammatory syndrome in children (MIS-C), between March 15 and May 20th

The median age of the patients was 8.3years old and 62% (115) were male. Fifty one patients (27%) had an underlying medical condition. In terms of confirmation of SARS_CoV-2 infection – 70% were positive for RT-PCR and/or antibody testing.  Of a small subgroup of 14 patients with Covid-19 symptoms before MIS-C, the median time between Covid-19 symptom to MIS-C was 25 days (6-51 days).
Criteria for MIS-C were based on CDC guidelines (in brief, requiring hospitalisation, at least two systems involved, fever of at least 24 hours and either lab confirmed SARS_CoV-2 infection (via RT-PCR or antibody testing) or an epidemiological link to a person with Covid-19 within 4 weeks before onset of symptoms).
Although MIS-C criteria was at least 2 system involvement, 71% had involvement of four organ systems or more. The most frequent systems in order were gastrointestinal (92%) followed by cardiovascular (80%), haematological (76%) and respiratory (70%). Blood changes observed included lymphocytopaenia in 80% of patients, and an elevated CRP in 91%.
Looking at similarity and overlap with Kawasaki disease, 40% of patients had either fever for at least 5 days and 4-5 of Kawasaki’s disease-like features or 2-3 Kawasaki’s disease-like features with additional lab or echocardiographic findings. Common symptoms similar to Kawasaki disease bilateral conjunctival infection in 103 (55%), oral mucosal changes in 78 (42%), peripheral extremity change in 69 (37%), rash in 110 (59%), cervical lymphadenoapthy (>1.5cm diameter) in 18 (10%). Differences between MIS-C and Kawasaki’s disease groups include an older age group and a different cardiovascular involvement (more likely myocardial dysfunction) in MIS-C patients.
The majority of patients required ICU admission (n=148, 80%) with one in five patients needing invasive mechanical ventilation. Eight patients received ECMO support. Treatment included IVIG in 77% and systemic glucocorticoids in 49%. There were four deaths (two of which had received ECMO). At the time of writing the paper, 70% of patients had fully recovered with 28% still in hospital.

Dufort EM, Koumans EH, Chow EJ, et al. Multisystem inflammatory syndrome in children in New York State. N Engl J Med. DOI: 10.1056/NEJMoa2021756.

This is a case series of 99 children (<21 years of age) from New York State with multisystem inflammatory syndrome in children (MIS-C). Of note some of these cases have been reported in small series (Cheung et al JAMA 2020). New York State Department of Health required hospitals that provide paediatric medical or surgical care to report potential cases of Kawasaki’s disease, toxic shock syndrome, or myocarditis or who were suspected to have MIS-C among persons younger than 21 years of age admitted since March 1, 2020, through the NYSDOH Health Emergency Response Data System. The clinical and laboratory characteristics of these reports were studied. Between March 1 and May 10 2020 191 cases were reported of which 95 met the criteria for MIS-C and 4 further were suspected.

Case definition: Confirmed cases were defined by the presence of both clinical and laboratory criteria. Suspected cases had clinical and epidemiological criteria.

Clinical criteria were children <21 years of age with fever and needing hospitalisation with either; 1 or more of hypotension or shock, features of severe cardiac illness, or other severe organ failure. Or 2 or more of; maculopapular rash, non-purulent conjunctivitis, mucocutaneous inflammatory signs or acute GI symptoms with an absence of other cause.

Laboratory criteria:

1. General Criteria; Two or more of raised inflammatory markers and

2. Either positive SARS CoV2 RNA at time of presentation or within 4 weeks or detection of specific antibody.

Epidemiological criteria: In 6 weeks prior to exposure close contact with a person with confirmed or clinically consistent Sars CoV2 infection or travel to or resident in an area with ongoing community transmission. 

Baseline characteristics: 53 (54%) were male. Age range was 0-5 years (31%), 6 to 12 year (42%) and  13 to 20 years (26%). 78 patients had data on race with 29 (37%) were white, 31 (40%) were black, 4 (5%) were Asian, and 14 (18%) were of other races. 36 patients had a preexisting condition, 29 had obesity.  24  (24%) had a Covid-19–compatible illness a median of 21 days (interquartile range, 10 to 31) before hospitalization, 38 (38%) had exposure to a person with confirmed Covid-19, and 22 (22%) had direct contact with a person who had clinical Covid 19.

Symptoms : Described in detail in the study. Prevalence of dermatologic symptoms was highest among children 0 to 5 years of age, and the prevalence of myocarditis (diagnoses and clinical) was highest among the adolescents.

Treatment : Of 99 patients, 79 were treated in ICU. 69 had IVIG, 63 received systemic glucocorticoids, 48  received both systemic glucocorticoids and IVIG. 9 patients had coronary aneurysm

Outcome : As of May 15, a total of 76 patients (77%) had been discharged and 21 (21%) were still hospitalised. Unfortunately 2 patients died in the hospital. Both were intubated and ventilated, once received ECMO. Neither received IVIG, systemic glucocorticoids, or immunomodulators.

Kaushik, S., S. I. Aydin, K. R. Derespina et al, “Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 Infection: A Multi-institutional Study from New York City.” J Pediatr.  https://doi.org/10.1016/j.jpeds.2020.06.045

This retrospective observational study details clinical characteristics, therapies and outcomes of a multicentre cohort of 33 children with Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 admitted to PICUs at 3 tertiary care children’s hospitals in New York City between 23 April and 23 May 2020.

Study design:  Patients aged 1 month to 21 years admitted to 3 NYC PICUs (at Children’s Hospital at Montefiore, Mount Sinai Kravis Children’s Hospital and Jacobi Medical Center) with confirmed SARS-CoV-2 infection (positive nasopharyngeal swab RT-PCR or antibody assay) meeting criteria for MIS-C (US CDC case definition, formalised on 14 May 2020, used: age < 21 yrs presenting with fever, laboratory evidence of inflammation and evidence of clinically severe illness requiring hospitalisation, with ³ 2 organ involvement, plus no alternative plausible diagnosis, plus positive for current/recent SARS-CoV-2 infection or COVID-19 exposure within 4 wks prior to onset of symptoms).  During the study period there were additional suspected patients with similar presentations and management without confirmed SARS-CoV-2 infection/exposure who were excluded; only cases with confirmed infection by RT-PCR/antibody assay were included. 

Study population:  33 children met the inclusion criteria at the 3 centres.  Median age 10 years (IQR 6-13), 20/33 male (61%), median BMI 18.6 kg/m2 (IQR 15.9-22.9), 2/33 obese (6%, BMI > 30 kg/m2).  15/33 Hispanic/Latino (45%), 13/33 black (39%), 3/33 white (9%), 1/33 Asian (3%), 1/33 other (3%).  16/33 comorbidities (48%) (most common comorbidity was asthma).  8/33 (24%) had had contact with an ill person, 5/33 (15%) had had contact with a confirmed COVID-19 case.

Clinical features:  Fever 31/33 (94%), mucocutaneous involvement 7/33 (21%), conjunctivitis 12/33 (36%), rash 14/33 (42%), abdominal pain 21/33 (64%), nausea/vomiting 23/33 (70%), diarrhoea 16/33 (48%), dyspnoea 11/33 (33%), dizziness 3/33 (9%).  Duration of symptoms prior to admission 4.5 days (IQR 3-6).  21/33 (64%) were hypotensive on admission.

Admission blood results:  Medians (IQR in brackets): WBC 11,000/mL (8450-14,400), lymphocytes 1,100/mL (600-1,300), CRP 250 mg/L (156-302), ESR 53 mm/hr (28-77), procalcitonin 5.4 ng/mL (1.8-16.7), ferritin 568 ng/mL (340-954), fibrinogen 627 mg/dL (455-782), D-dimer 3.7 mg/mL FEU (2.4-5.1), BNP 388 pg/mL (75-1086), pro-BNP 4328 pg/mL (2117-13370), troponin T 0.08 ng/mL (0.02-0.17), IL-6 200 pg/mL (56.4-330), IL-8 41.7 pg/mL (25.1-54.4), creatinine 0.6 mg/dL (0.4-1.1).

CXRs:  Cardiomegaly 10/33 (30%), focal or bilateral pulmonary opacities 11/33 (33%).

Echocardiograms:  Performed in 32/33 (97%).  Pericardial effusion 15/32 (47%), median LVEF 47% (IQR 40-53).  LVEF < 30% 4/32 (13%), LVEF 30-50% 17/32 (53%), LVEF > 50% 11/32 (34%).  24/32 had a second echocardiogram prior to discharge: of those with initial LVEF < 50%, 20/21 (95%) had recovery of ventricular function with normal EF.  Median pre-discharge LVEF 58% (IQR 55-62).  A detailed table is supplied for the 21 patients with LVEF < 50%, including BNP/troponin levels, drug treatment by patient and the 8/21 who had prominent coronary arteries on echo.

Treatment in PICU:  18/33 received IVIg (55%), 17/33 corticosteroids (52%), 12/33 tocilizumab (35%), 7/33 remdesivir (21%), 4/33 Anakinra (12%), convalescent plasma therapy 1/33 (3%), 17/33 vasopressor/inotropes (52%) (median duration of vasopressor use 72 hrs (IQR 48-110), norepinephrine most commonly used agent), 8/33 aspirin (24%), 21/33 diuretics (64%).  Anticoagulation was used in all patients:  prophylactic dose enoxaparin 5/33 (15%), therapeutic dose enoxaparin 27/33 (82%), therapeutic dose unfractionated heparin 1/33 (3%).  Empiric antibiotic coverage for < 48 hrs in 14/33 (42%) and > 48 hrs in 15/33 (45%).  5/33 (15%) required invasive mechanical ventilation.  2/33 (6%) required mechanical circulatory support: 1 ECMO (5-yr-old) and 1 intra-aortic balloon pump (20-yr-old).

Outcomes:  32/33 (97%) patients were discharged home with median PICU stay of 4.7 days (IQR 4-8) and hospital stay of 7.8 days (IQR 6-10).  1/33 (3%) died (ischaemic brain infarction with subarachnoid haemorrhage on day 6 of ECMO).

The authors conclude that rapid, complete clinical and myocardial recovery was almost universal in their study.  They hypothesise that this novel COVID-19 MIS-C is predominantly an antibody-mediated or other immune cell-mediated cytokine storm, with some contribution from direct myocardial injury.  They note the lower morbidity in their cohort relative to recent European studies

Capone, C. A., A. Subramony, T. Sweberg, J. et al. “Characteristics, Cardiac involvement, and Outcomes of Multisystem Inflammatory Disease of Childhood (MIS-C) Associated with SARS-CoV-2 Infection.” J Pediatr. https://dx.doi.org/10.1016%2Fj.jpeds.2020.06.044

This is a single-centre retrospective case series of 33 sequentially hospitalized febrile paediatric patients with CDC case definition for Multisystem Inflammatory Disease of Childhood (MIS-C) and WHO criteria for Multisystem Inflammatory Syndrome (MIS) admitted to Cohen Children’s Medical Center, Queens, NY from April 17, 2020 through May 13, 2020. All cases were positive for SARS-CoV-2 by detection of serum antibodies or nucleic acid from a nasopharyngeal specimen. Patients with COVID-like lower respiratory tract involvement were excluded. The peak of hospitalizations occurred approximately five weeks after the peak of hospitalizations with acute COVID-19. Patients were predominantly male (20, 61%) and non-Hispanic (24, 73%) with a median age of 8.6 years (IQR 5.5-12.6). Most patients were previously healthy but a higher proportion were overweight (2,6%) or obese (12, 39%) compared with the regional childhood obesity rate of 18%. 

Patients presented with a median of 4 days (IQR 3-5) of fever and almost all (32, 97%) had gastrointestinal symptoms (including diarrhoea, vomiting and abdominal pain) as well as other organ system involvement. 21 (64%) patients fulfilled complete criteria for KD and most patients with complete KD criteria, had shock (16, 76%). 

All patients had negative blood cultures and multiplex nucleic acid amplification test for multiple respiratory pathogens except 1 patient in whom influenza virus detected. 26 (79%) patients needed intensive care and 6 (18%) required mechanical ventilation. 58% had myocardial dysfunction and 76% required vasoactive medications. Coronary artery aneurysm was identified in 5 (15%) and dilation was detected in 3 (9%) patients. 

All patients were treated with IVIG, 88% received aspirin, and 70% were given a corticosteroid and 42% were given Enoxaparin. 24% of patients exhibited a partial response to these treatments and received a biologic modifying medication (Anakinra, Tocilizumab, Infliximab). Most patients demonstrated rapid clinical improvement. No patients died. Median length of hospital stay was 4 days (IQR 4, 8). At hospital discharge, mild cardiac dysfunction was still present in 9 of 19 patients. 

This case series shares similarities with smaller international case series reported as Kawasaki-like disease and hyperinflammatory shock syndrome. In all these studies, most patients had antibodies against SARS-COV2 virus, suggestive of a post-infectious, immunologically mediated pathophysiology. The authors suggest that the latent period between the peak of paediatric cases of COVID-19 and MIS-C suggests that MIS-C has a post-infectious, possibly immunologically mediated pathogenesis.

Despite clinical similarities with KD, differences include the predominance of gastrointestinal symptoms, an older age range (8.6 year in MIS-C patients compared with a median age of 2.5 years for patients with KD), markedly elevated inflammatory markers, higher proportion of patients with shock and/or impaired cardiac function (76%) than in other KD studies (less than 3% shock reported), and the lack of thrombotic events in the case series patients. This suggests that MIS-C may be a syndrome distinct from KD. Acute COVID-19 with “cytokine storm” further complicates differentiation of these presentations.  

Further study is needed to shed light on the pathophysiology, treatment options, and outcomes of MIS-C.

Whittaker, E., A. Bamford, J. Kenny, et al. “Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2.” Jama. doi:10.1001/jama.2020.10369

This paper provides a detailed description of the clinical and laboratory features of 58 children diagnosed with PIMS-TS from 8 hospitals in England between March 23rd and May 16th 2020. All children fulfilling the UK, WHO or CDC criteria for PIMS-TS / MIS-C were included; evidence of SARS-CoV-2 infection was not required for inclusion. Features of this group were compared with previous data from children with Kawasaki Disease (KD), KD shock syndrome (KDSS) and toxic shock syndrome (TSS).

Of the 58 patients, 45 (78%) had evidence of SARS-CoV-2 infection (RT-PCR (15) and or IgG (40)). 33 (57%) were female. 22 (38%) were of black race, 18 (31%) asian. The majority were previously well; only 7 had co-morbidities (3 with asthma, 1 epilepsy, 1 neuro-disability, 1 sickle cell trait, 1 alopecia)

All patients had fever (range 3-19 days). Gastrointestinal symptoms were common (abdominal pain (53%), diarrhoea (52%), vomiting (45%)) whilst respiratory symptoms were relatively uncommon (21%) and 15 (26%) had headache. 

Only 13 (22%) of patients fulfilled criteria for KD; 8 (14%) had coronary artery aneurysm, 26 (45%) conjunctival injection, 30 (52%) rash, 17 (29%) mucous membrane changes, 9 (16%) lymphadenopathy, and 9 (16%) swollen hands and feet. Half of patients developed shock. 

Laboratory findings were consistent with marked inflammation (mean CRP 229 mg/L (IQR 156-338), ferritin 610 μg/L (359-1280), fibrinogen 5.7 g/L (4.4-7), D-dimer 3578 ng/mL (2085-8235)) with neutrophilia (13 x 10^9 (10-19)). Evidence of myocardial injury was common with troponin elevated in 34/50 (68%) and NT ProBNP in 24/29 (83%). Low haemaglobin (92 g/L (83-103)), lymphocyte (0.8 x 10^9 (0.5-1.5) and platelet levels (151 x 10^9 (104-210)) were also observed. 

Half of patients were admitted to a critical care unit; 25 (43%) requiring mechanical ventilation, 27 (47%) inotropes and 3 (5%) ECMO. A range of treatments were given including IVIG (71%), steroids (64%), anakinra (5%) and infliximab (14%). 13 (22%) recovered without immunomodulatory treatment, whilst 60% received >/= 2 and  16% >/= 3 agents. To the last date of follow up only one child had passed away. 

The authors suggest three clinical patterns of PIMS-TS based on the patients included in this series: 

  (1) persistent fever and elevated inflammatory markers (without KD, shock or organ failure) – 23 patients here

  (2) fever and shock, often with myocardial dysfunction – 29 patients 

  (3) children fulfilling criteria for KD – 7 patients (13 if aneurysm included in criteria). 

Compared with children with KD, KDSS and TSS, children with PIMS-TS were older (median age 9 (IQR 5.7-14)) with higher CRP and lower haemaglobin. Compared with those with KD and KDSS, PIMS-TS patients in this series had higher neutrophil count, ferritin and troponin with lower platelet and lymphocyte counts. Compared with pre-COVID-KD cases children with PIMS-TS KD were older and had higher markers of inflammation and myocardial injury. 

This is the most detailed clinical report of PIMS-TS to date. The findings here demonstrate a syndrome with a wide spectrum of signs, symptoms and severity with some overlap with KD, KDSS and TSS. PIMS-TS is characterised by marked inflammation with myocardial dysfunction and often shock necessitating ICU admission for inotropic support, mechanical ventilation and, in a small number of patients, ECMO. Treatment with immunomodulatory agents similar to those used in KD has been employed and only one death had occurred at the time of the report. Differences in clinical and laboratory profile compared with KD, KDSS and TSS, suggests= that PIMS-TS is a unique entity, potentially arising from a maladaptive acquired immune response to SARS-CoV-2 infection. 

Cheung EW, Zachariah P, Gorelik M, et al. Multisystem Inflammatory Syndrome Related to COVID-19 in Previously Healthy Children and Adolescents in New York City. JAMA. Published online June 08, 2020. doi:10.1001/jama.2020.10374

This is a case series of 17 children, admitted to a hospital in New York city, between April 18th and May 5th 2020 with features of Multisystem Inflammatory Syndrome Related to COVID-19.

Patients included in this series were i. less than 21 years old, ii. presented with a clinical syndrome characterized by prolonged fever, systemic inflammation, shock, end-organ dysfunction, or symptoms reminiscent of Kawasaki Disease or Toxic Shock Syndrome and iii. had evidence of recent (SARS-CoV-2) infection. The baseline characteristics of these children were; median age 8 years (1.8-16), 8 were male (47%); 12 were classified white (70.1%), 4 black (23.5%), 1 Asian (5.9%).

Presentation: All had fever, with median duration of 5 days. 14/17 had GI symptoms. Mucocutaneous findings were common (12 rash, 11 conjunctivitis, 9 lip redness/swelling). 3 were hypoxic at presentation, and 13 had shock. 8 met criteria for KD and 5 for incomplete KD.

Investigations: 8 patients tested positive for SARS-CoV-2 by RT-PCR and 9 by serology.

Xrays: 14 had abnormal chest radiograph findings, most commonly bilateral, interstitial opacities.

Bloods: mean values for a wide variety of investigations shown in paper in table 2. Mainly group were lymphopenic with raised ferritin, d dimers, clotting times, and troponin.

Cardiac: ECG of 16 patients showed nonspecific ST/T-wave abnormalities in 10 and attenuated QRS voltage in 1. Dysrhythmias were noted in 3. Admission echos showed normal to mildly decreased left ventricular function in 11,  or moderate or more ventricular dysfunction in 6.  All patients had normal coronary arteries by measurement, though coronary arteries were described as prominent or echogenic in 7. However one patient (aged 4 years) developed a medium-sized aneurysm (z score, 5.2) of the left anterior descending coronary artery. This patient presented with fever, diarrhea, and shock, with no additional features of KD.

Treatment: 15/17 patients were admitted to PICU; vasoactive support was required in 10. Treatment was varied, 14 received steroids (either methylprednisone or hydrocortisone, prednisolone numbers of each not given). 13/17 received IVIG including 3 patients who did not receive steroids and 8 who met criteria for KD. One patient received tocilizumab.

Outcome: All patients discharged home with no fatalities.

Comparison with other PIMS TS cohorts:

Reports of hyperinflammatory syndrome in children during the Sars CoV2 outbreak has been reported in France, Italy, UK and US. (see https://dontforgetthebubbles.com/pims-ts/)

This cohort used the CDC definition, which is broadly similar to RCPCH and WHO, though in the US paediatrics < 21 years of age.

Like the other cohorts, the age range is older than typically seen in Kawasaki Disease. Fever and GI symptoms are very common. Mucocutaneous signs were also common. Children presented very unwell, with many needing PICU care (88% in this study). Treatment used included IVIG and steroids.

Unlike other cohorts where black ethnicity was pronounced, 70% of this cohort was classified as white. It would be useful to know the demographic breakdown of the local paediatric population who attend this hospital.

Belot, A., D. Antona, S. Renolleau, et al. SARS-CoV-2-related paediatric inflammatory multisystem syndrome, an epidemiological study, France, 1 March to 17 May 2020.” Euro Surveill 25(22). June 4th 2020, https://doi.org/10.2807/1560-7917.ES.2020.25.22.2001010

The first epidemiological surveillance study of SARS-CoV-2-related paediatric inflammatory multisystem syndrome (also known as PIMS-TS).  Carried out in France (population: 67 million) this was a nationwide study through the French public health agency.  156 cases were reported between 1st March and 17th May 2020 through both prospective and retrospective case identification.

Case definition required one or more of the following symptoms: seritis (serositis), characteristics of macrophage activation syndrome (MAS), myocarditis and/or Kawasaki-like disease (KLD).  Cases were divided according to associated Covid status into confirmed, probable or possible CoV and non-CoV.  Comparison was undertaken between non-CoV PIMS and CoV PIMS.

Of note, this definition differs marginally from the UK RCPCH definition of PIMS-TS which is a child with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopaenia) and evidence of single or multi-organ dysfunction.

Age distribution showed a median of 8 years and an interquartile range of 5–11 years.  Peak incidence was week of 18th to 27th April, which was 4-5 weeks behind the peak of the Covid-19 epidemic in France. 

95 of the 156 reported cases were confirmed or probable Covid, supporting a causal link between Covid-19 infection and PIMS.

CoV-PIMS cases (n=108) compared with non-CoV PIMS cases (n=48) had a higher median age (8 vs 3) and showed higher rates of myocarditis (70% vs 10%), macrophage-activation syndrome (23% vs 2%), seritis (22% vs 10%) and ITU admission (67% vs 8%). Rates of Kawasaki-like disease (KLD) were higher in the non-CoV group (81% vs 61%0) supporting the idea that these are ‘classic’ Kawasaki Disease presentations. In the CoV-PIMS groups 73% required vasopressors, 43% were ventilated and one child died.

This is the first epidemiological surveillance study of PIMS-TS indicating rates across a population. It supports a causal link with Covid following 4-5 weeks behind the clinical illness.

Belhadjer Z, Méot M, Bajolle F, Khraiche D, Legendre A, Abakka S, Auriau J, Grimaud M, Oualha M, Beghetti M, Wacker J. Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic. Circulation. 2020 May 17. doi: 10.1161/CIRCULATIONAHA.120.048360

A multi-centred retrospective case series studied the early outcomes for children admitted to intensive care for cardiogenic shock, left ventricular dysfunction and severe inflammatory state. The study involved 14 centres in France and Switzerland. The inclusion criteria were admission between 22nd March and 30th April 2020 with fever (>38.5°C), cardiogenic shock or left ventricular dysfunction (left ventricular ejection fraction<50% in the presence of an inflammatory state (CRP> 100 mg/mL).

In summary, left ventricular systolic dysfunction was present in all patients who experienced a low systolic blood pressure. The authors contrast this to Kawasaki disease, in which diastolic dysfunction predominates and only a third of patients experience left ventricular systolic dysfunction.

The authors suggest the rapid resolution of systolic dysfunction in conjunction with a mild to moderate troponin rise implies the mechanism of cardiac impairment associated with SARS-CoV2 in the paediatric population differs to that seen in the adult population. Due to the high BNP levels present in the case series a mechanism of myocardial oedema or stunning is suggested. Very high levels of Interleukin-6 were also seen and may be related to vasoplegia. It was hypothesised these significantly raised results could be caused by stretched cardiomyocytes and cardiac fibroblasts in conjunction with macrophage activation. However, further research would be required to determine the immune mechanisms involved and potentially guide treatment choices.

35 patients were included with a median age of 10 years (IQR 2-16 years), 18 were male. 31 patients were confirmed SARS-CoV2 positive by either a nasopharyngeal RT-PCR, faecal RT-PCR, tracheal swab, or serology using Chemiluminescent Microplate Immunoassay-CMIA technique. 2 other patients were SARS-CoV2 negative, however, had CT chest appearances consistent with SARS-CoV2 changes.

10 of the patients had an identified co-morbidity: 3 (8.5%) had asthma, 1 (3%) had lupus and 6 (17%) were overweight with a BMI greater than 25. There was no data regarding ethnic origin included.

Clinical features: 35 (100%) had fever, 35 (100%) Asthenia, GI symptoms 29 (83%), rhinorrhoea 15 (43%), respiratory distress 23 (65%), adenopathy 21 (60%), rash 20 (57%), meningism 11 (31%), chest pain 6 (71%), cardiogenic shock 28 (80%), ventricular arrhythmia 1 (3%). A large proportion of the patients had shock with low systemic blood pressure with limited information.

Radiology: 2 patients had CT chest appearances “typical” for those with SARS-CoV2.

Bloods: CRP 241 mg/mL (IQR150-311) mg/mL, Troponin I 347 (IQR 186-1267) ng/L (normal <26ng/L), Creatinine Kinase 174 U/L (IQR 110-510), NT-proBNP 41484 pg/mL (IQR 35811-52475) (normal <300 pg/mL), BNP 5743 pg/mL (IQR 2648-11909) normal <100 pg/mL), D-Dimer 5284 ng/ml (IQR 4069-9095), Procalcitonin 36 ng/ml (IQR 8-99), WCC 16 X 10^3/L (IQR 12-23), Neutrophil count 13 X 10^3/L (IQR 8-19), Interleukin 6 135 pg/mL (IQR 87-175) (normal <8.5 pg/mL) 

Treatments: All patients required intensive care management with 10 (28%) needing V-A ECMO for an average of 4.5 days (range 3-6), 28 (80%) needing inotropic medication, 22 (62%) invasive ventilation and 11 (32%) non-invasive ventilation.

25 (71%) were given intravenous immune globulin with 1 (3%) patient given repeated IVIG due to persistent fever 48 hours after the first dose. 12 (34%) received intravenous steroids, dose unclear, due to grading them high-risk with symptoms similar to an incomplete form of Kawasaki disease and 3 patients received interleukin 1 receptor antagonist (anakinra) due to a persistent severe inflammatory state. 23 patients received therapeutic heparin.

Outcomes: No patients died. All 10 patients requiring V-A ECMO were weaned off successfully. The average hospital stay was 8 days (IQR 8-14) with ICU duration of 7 days (3.7-10 days). At the time of publication 7 (20%) patients remained as an inpatient or had residual left ventricular dysfunction.

Complete recovery of left ventricular function, [left ventricular ejection fraction > 60% at day 7] was seen in 25 patients (71%) by an average of 2 days after admission. 5 (14%) had residual mild to moderate left ventricular systolic dysfunction with a left ventricular ejection fraction greater than 45%. This was measured on the last follow up, an average of 12 days after admission.

Other investigations were undertaken to assess cardiac function.

ECG: 1 patient (3%) had ST elevation on ECG.

Echocardiography results: 10 (29%) of patients had an ejection fraction below 30% on admission whilst 25 (71%) had an ejection fraction between 30 and 50%. Global hypokinesis was seen in 31 (89%) with an additional 3 (9%) patients had segmental wall hypokinesis. 1 (3%) patient had Takotsubo syndrome presentation with akinesis of the apical segment Pericardial effusions were diagnosed in 3 (9%) patients.

Coronary artery dilatation, defined as Z-score >2 adjusted for body temperature, was present in 6 patients (17%): 5 patients (14%) had dilatation of the left main stem and 1 (3%) had dilatation of the right coronary artery. Right ventricular function was normal, and no thrombi were seen. No coronary aneurysms have been seen, however, ongoing follow up is planned.

Data was not presented regarding SARS-CoV2 antibodies, however, within the discussion it was noted that those who were serologically positive for SARS-CoV2 already had IgG antibodies suggesting the patients included within the study had contact with the virus “more than 3 weeks before admission”.   

Toubiana Julie, Poirault Clément, Corsia Alice, Bajolle Fanny, Fourgeaud Jacques, Angoulvant François et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study BMJ 2020; 369 :m2094

This cohort study looks at a cluster of patients diagnosed with Kawasakis disease at a hospital in Paris between April 27th and May 11th. During this time they admitted 21 children with a diagnosis of Kawasakis or incomplete Kawasakis, with a median age of 7.9yr and 12/21 female.

Clinical features: All children presented with persistent fever and with initial GI symptoms (vomiting and diarrhoea) with over half fulfilling complete KD criteria (11/21, 52%). The majority were irritable (12/21, 57%) and myocarditis was common (16/21, 76%). Coronary artery dilation was seen in 5/21 (24%) but no aneurysms seen. 8/18 who had chest imaging had lung changes.

Bloods: Inflammatory markers were significantly raised, with a median CRP of 253, PCT 22.5 and IL-6 170. Interestingly mean platelet count was 499 (but up to 838). Median troponin 282 and D dimer 4025 (up to 19330). Ferritin not reported.

COVID-19 status: 8/21 tested positive on swab and 19/21 had positive serology

Treatment: All were given IVIg, following which 5/21 still had fever 36hrs afterwards. They were given a second dose of IVIg and steroids. 15/21 required inotropic support and 11/21 required intubation/ventilation.

Outcomes: Median length of stay was 8 days (rage 5 – 17). There were no deaths.

Three subsequent studies have confirmed very similar presentations of this hyperinflammatory syndrome (PIMS-TS) in children, with initial abdominal pain, fever, diarrhoea and vomiting, progressing to a picture similar to Kawasakis disease but with a significant number developing shock and significant cardiac involvement.

Riphagen, Shelley et al., Hyperinflammatory shock in children during COVID-19 pandemic, The Lancet, May 7th 2020, https://doi.org/10.1016/S0140-6736(20)31094-1

This is the first case series to describe a cluster of children presenting with hyperinflammatory shock during the COVID-19 pandemic.
Eight children aged 4 to 14 years were identified by a paediatric retrieval service based in London in mid-April 2020. Interestingly, of the 8 children, 7 had weights >75th centile. Notably 6 were of Afro-Caribbean descent and 2 were Asian, with no Caucasian children in this cohort. 5/8 were boys. 4 children had exposure to family members with COVID-19.

The clinical presentation was similar to Kawasaki disease, with unrelenting fever, rash, conjunctivitis, peripheral oedema, and extremity pain, in addition to gastrointestinal symptoms. All children developed warm, vasoplegic shock and required inotropic support. Seven children required mechanical ventilation.

Small pleural, pericardial and ascitic effusions, also consistent with a diffuse inflammatory process were also observed. Vascular involvement was demonstrated with echo-bright coronary arteries seen in all children, with a giant coronary aneurysm in one patient. One child died from a large cerebrovascular infarct. Myocardial enzymes were significantly elevated.

A range of investigations were done in all children, and despite this no causative pathogen was identified. Adenovirus and enterovirus were isolated in one child. Four children had known exposures to SARS-CoV-2 in family members, but only two tested positive for SARS-CoV-2 (1 was positive only postmortem). 

In addition to other supportive therapies, all children received IVIG and broad-spectrum antibiotics (ceftriaxone, clindamycin). Six children have been given aspirin.

This clinical presentation may represent a new phenomenon associated with SARS-CoV-2 infection in children and has remarkable similarities to Kawasaki Disease. Following publication of this case series, Evelina London Children’s Hospital has managed >20 similar cases in children. Ten of these children were SARS-CoV-2 antibody positive (unclear which antibody or which test was used).

These findings have garnered particular interest due to the fact that children have otherwise been relatively spared from severe disease due to COVID-19, and here both the temporal association and high proportion of children with seemingly positive serology suggests a possible association with this hyperinflammatory syndrome. Anecdotally, clusters have also been noted in the USA (particularly NYC) and some centres in Spain and Italy. Reports are conspicuously absent from Asia, most notable as Kawasakis disease is more common amongst this population normally. Even more striking is the gross overrepresention of children with an Afro-Carribean background, which given current investigations into the increased incidence of severe adult disease in these communities seems even more pertinent.

As so little is currently known about “garden variety” Kawasakis, it will make defining this disease and its associated with COVID-19 that bit more difficult, but studies are currently ongoing to assess the nature and mechanism of this disease (https://www.diamonds2020.eu/). For now, this cohort doesn’t change the management of childhood COVID-19, nor does it change the management of hyperinflammatory shock or Kawasakis – although the RCPCH have produced excellent guidance for suggested investigations and processes to include these patients in ongoing research.

Paediatric COVID data

First authorLast authorJournalArticle titleDate of PublicationCountryRegion(n) childrenStudy typePaper linkReview
Han, MSChang, SHJAMA PaediatrClinical Characteristics and Viral RNA Detection in Children With Coronavirus Disease 2019 in the Republic of Korea28 Aug 2020KoreaAsia91Clinical - Clinical Featureshttps://jamanetwork.com/journals/jamapediatrics/fullarticle/2770150

This Korean case series examined children aged 0-18 years with COVID-19 who presented across 22 facilities (20 hospitals) from February 18-March 31st 2020. It focuses on clinical features and duration of SARS-CoV-2 RT-PCR detection. A total of 91 were identified by SARS-CoV-2RNA RT-PCR on nasopharyngeal/oropharyngeal or sputum swabs due to testing for one of the following reasons: symptomatic, close contact with a confirmed case, testing as apart of outbreak or screening on return from overseas.

Demographics included 53 (58%) male cases, with the median age being 11 years (range 27 days - 18 years). The majority (85, 93%) were previously well. Of the 6 with underlying medical conditions, 3 had asthma and epilepsy respectively.  Exposure was from a household contact in 57 (63%) of cases, with 15 (17%) imported, 11 (12%) cluster-associated, 4 from another contact and 4 remaining an unknown source.

Cases were mostly mild (46, 51%) or asymptomatic 20 (22%). There were 20 moderate, 2 severe cases and 3 unclassified. No children required mechanical ventilation. Fever ≥  38 as seen in 27 (30%) of patents, 54 (60%) had cough or coryza , 8 had loss of smell or taste, 5 had anosmia and 16 (18%) had gastrointestinal symptoms including diarrhoea and abdominal pain. Only one patient had gastrointestinal symptoms without fever or respiratory symptoms. Two thirds of children had symptoms prior to diagnosis (median time 3 days). The duration of symptoms for cases lasted a median of 11 days (range 1-36 days).

The children were tested for SARS-CoV-2 repeatedly to determine cessation of virus RNA detection, however intervals were not standardised, with a median of 3 days (range 1-15 days). Children who were asymptomatic had virus RNA detectable for an average of 14.1 days, and those with URTI or LRTI symptoms, at 18.7 and 19.9 days respectively (difference between these groups was not significant). Twelve children were given treatment with lopinavir-ritonavir and two with hydroxychloroquine. There was no difference in detection between the groups treated with the antiviral lopinavir-ritonavir or not.

This study confirms what many previous studies have demonstrated, which is that children with SARS-CoV-2 can remain PCR positive for prolonged periods. This study adds that this is also the case for children who do not develop symptoms. What is unclear is for how long this represents live virus with replicative potential. Culturable virus has not been detected beyond day 8 of symptoms. The authors of this study did not provide ct values which would enable some estimate of the presence of culturable virus (low ct values usually represent viral fragments).

Yonker, LFasano, AjpedsPediatric SARS-CoV-2: Clinical Presentation, Infectivity and Immune Responses19 Aug 2020USANorth America192Clinical - Clinical Featureshttps://www.jpeds.com/article/S0022-3476(20)31023-4/fulltext

This is an observational cohort study from Massachusetts General Hospital, Boston, USA

192 "children" (ages were 0-22 years) were enrolled when they presented with possible Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) at urgent care clinics (with symptoms or because of contact with a case) or were hospitalised with confirmed/ suspected SARS-CoV-2 or Multisystem Inflammatory Syndrome in Children (MIS-C). Dates of enrolment are not given.

Samples were collected after consent/assent: Nasopharyngeal swabs (83 samples), oropharyngeal swabs (105) and blood (100). Viral load was determined from respiratory and plasma samples, and ACE2 expression in the upper airways from the swabs.

Results

125(65%) children were SARS-CoV-2 negative, 49(26%) had acute SARS-CoV-2 infection and 18(9%) had MIS-C. MIS-C children were more likely to be younger and male.

.80% of the SARS-CoV-2(+) children had a known household contact but so did 44% of the SARS-CoV-2(-) and 45%of the MIS-C children. SARS-CoV-2(+) and (-) children presented similarly with non-specific symptoms, and anosmia occurred in 20% of the SARS-CoV-2 (+) group. MIS-C children most commonly had fever, followed by nausea and vomiting, and rash. There was no significant prevalence of any co-morbidities in any of the groups

Viral load in the respiratory samples of the SARS-CoV-2(+) was comparable to adults despite mild or absent symptom even in the youngest children. A comparison is made between children within 2 days of symptom onset and hospitalised adults after 7 days of symptoms, which is unhelpful as these time points are clearly not comparable (viral load rapidly decreases after onset of symptoms).

SARS-CoV-2 antibody response data is presented and is said to show a generalised enhancement of humoral immune responses as a marker of severe MIS-C

ACE2 gene expression of the upper airway was quantified by NP/OP swabs from both infected and non-infected children. ACE2 levels were higher in those with infection of SARS-CoV-2 and those with MIS-C (difference 10-4 – 10-5 log, p=0.004), and there was an increase of ACE2 expression with age, although with high variability. There was no association between ACE2 expression and viral load.

In summary, this study confirms a number of already known elements regarding children with COVID-19 or MIS-C, including that viral loads appear comparable to adults and that many symptoms are non-specific. This study confirms increasing ACE2 expression with age, which may in part explain reduced susceptibility to acquiring infection. Of interest is lack of correlation between viral load and ACE2 expression. Despite strong claims about transmission by the authors, the study does not address this question or add new information on this point.

Carter, MShankar-HariNat MedPeripheral immunophenotypes in children with multisystem inflammatory syndrome associated with SARS-CoV-2 infection18 Aug 2020United KingdomEurope25Clinical - Clinical Featureshttps://www.nature.com/articles/s41591-020-1054-6.pdf

This study examines the peripheral leukocyte phenotype of children with multi-system inflammatory syndrome in children (MIS-C).

A total of 25 children with a median age of 12.5 (range 7.7-14.4) were included. Clinical features of MIS-C were most commonly gastrointestinal symptoms (72%), polymorphous non-blanching rash (48%), and bilateral non-purulent conjunctivitis (40%). Only 2 (8%) children met criteria for Kawasaki Disease. Of note, 7 (30%) had coronary artery aneurysms. Treatments during admission included high-dose corticosteroids (80%), intravenous immunoglobulin (92%) and biologic agents (56%). Majority (84%) required admission to the paediatric intensive care, however only 2 (8%) of children required mechanical ventilation. Only 1 child (4%) was positive for SARS-CoV-2 PCR, however 17 (68%) were SARS-CoV-2 IgG antibody positive.

Leukocyte phenotyping was done during the acute (n=23), resolution (n=14), and convalescent (n=10) phase of illness. In the acute phase of illness, elevated levels of interleukin-1β (IL-1β), IL-6, IL-8, IL-10, IL-17, interferon-γ and differential T an B cell subset lymphopaenia were observed. In addition, there were decreased levels of HLA-DR and CD86 expression on antigen-presenting cells. Interestingly, the differential expression of these markers and elevated cytokines resolved as the child recovered.

This important study demonstrates that MIS-C is a distinct immunopathogenic illness. Future studies including larger cohorts of children will be critical in rational development of future therapies for this condition.

Liu, XChen, JJ Infect DisClinical and epidemiological features of 46 children under 1 year old with coronavirus disease 2019 (COVID-19) in Wuhan, China: a descriptive study 6 Aug 2020ChinaAsia46Clinical - Clinical Featureshttps://watermark.silverchair.com/jiaa472.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAArgwggK0BgkqhkiG9w0BBwagggKlMIICoQIBADCCApoGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMRenTM0H7AWkHfH5OAgEQgIICa-S2TrctCjayBEO6MxumGRv8cRCshq5YspREyle7HGSz423KjAOkoj9JVSjYnFYK-4AQk_PsUNKgNEiFcKtzxQmmPcFQb4_qXmXXRN7VEKAErKU6bCp94py_9BedSlJbOqx2wvSTyzCA3lx5EpyXjnzmnkGejTdhXYkihOkNa25518np1FWNH7Q3yt3fdkYKfpw-iC8JoXgTZeJUTVn3gwt2t62nwQFHoHNkpQN4lkSFOLRJgvs_n1BJODja2d5JhsOn8kwMg0iQNMzsqNjtaeRa9DjqjejOXaabpQIBrBHGf6HmCENuAy3DkuJTHMSPhMzvScKHa3aTV6n6ue80OZIFX__w-ak7J6YVTNidfBkPIWXL0dX3jVSJlz43rmZLjNi6ybjK5MJA3nBqcN0_ooufj4DNH649asuiXPGEYzuhWfKaIcszBlAIDDIofvOdkMo5B5f1FKWwO-dugrZaOeuO94nPclWiKD5_B_qZX45eBO_a00oSKZYejJho2I6-z19l7qtekqRqIb9ETv4zrSqcguK2sP7wctnmntr3DirqK6Pdp3xs7UCoS_TOvmZgV2o8K8KEMZWHykkK-Zt_Aw5bJNT6_T8-WqNd9saE5ic49bnVRsItNtTaiOqmTjWaOzwvdObd69sTvy6acaya1fL2N5e0fveNorCnz-5AJZtgg0cXZH9mh1Y72xmTPA8EaGRhPoIZ8tNbSfWs21pVDfFoGJNRUhMM1HpJ6V62jpoQ1mDPS-_QD3KqpStGg4QOgyv60xYT3iPz0MND03xLjlqIbbqH-dXQ7w6vuBS_PTgaW7Wa_pduFkGIY_c

This restrospective case series study analyses the clinical features of 46 infants less than 1 years old who were confirmed to have COVID-19 at Wuhan Children’s Hospital (China) between the period 26th January 2020 to 15th March 2020. It was not described how these patients were identified for the study. 25 patients (54.35%) were male and 21 (45.65%) were female. The median age was 5 months (IQR 2-7 months). The authors classed 2 patients (4.35%) as having severe or critical disease, 40 patients (86.96%) as moderate disease, 2 patients (4.35%) as mild disease, and 2 patients (4.35%) as asymptomatic. Sadly one patient (2.17%) died (age 10 months), and the remaining 45 (97.83%) were discharged home.

Cough (n=27; 58.7%) and fever (n=16; 34.78%) were the predominant features, with a minority of other patients experiencing vomiting (n=5; 10.87%); Nasal congestion and rhinorrhoea (n=3; 6.52%); dyspnoea (n=1; 2.17%); tachypnoea (n=1; 2.17%); diarrhoea (n=1; 2.17%); and sneezing (n=1; 2.17%).

With regards to complications, the following were found: liver dysfunction (n=20; 45.45%); cardiac injury (n=38; 86.36%); acute gastroenteritis (n=3; 6.52%); multiple organ dysfunction syndrome (n=1; 2.17%); required mechanical ventilation (n=2; 4.35%).

Common laboratory findings included: Lymphocytosis (n=13; 28.26%); raised ALT (n=11; 25.00%); raised AST (n=20; 45.45%); raised lactate dehydrogenase (n=23; 52.27%); raised creatine kinase (n=10; 22.72%); raised creatine kinase MB (n=38; 86.36%); raised CRP (n=8; 19.05%); raised CD3+ T cell (n=10; 28.57%); raised CD4+ T cell (n=14; 40.00%); raised CD19+ B cell (n=16 patients; 47.51%); raised IL-10 (n=15; 44.12%).

Caro-Dominguez, Pvan Rijn, RPediatr RadiolThoracic imaging of coronavirus disease 2019 (COVID-19) in children: a series of 91 cases4 Aug 2020Spain, Italy, France, Iran, USA, Switzerland, Germany, Sweden, Hong Kong, Netherlands, UK and Mexico International91Clinical - Clinical Featureshttps://link.springer.com/article/10.1007/s00247-020-04747-5

This international multicentre retrospective study of 91 children with confirmed SARS-CoV-2 describes the radiological findings of their chest imaging. Data was included from Spain, Italy, France, USA, Switzerland, Germany, Sweden, Hong Kong, Netherlands, UK and Mexico. Chest x-rays were reviewed independently by 3 senior paediatric radiologists. Chest CT images were evaluated by a different group of 3 senior paediatric radiologists. Impressions were shared and consensus reached for each image.

Of the 91 children, 11% had severe symptoms requiring PICU and 30 (33%) had coexisting medical conditions including 16 immunocompromised children, 7 children with congenital heart disease and 7 with long-term respiratory conditions. Six (7%) children were asymptomatic.

81 (89%) of the children in the study had chest x-rays. Of these, 10% were entirely normal despite the children being SARS-CoV-2 positive. None of the children with a normal x-ray required PICU admission. The most common abnormal x-ray findings were increased central peribronchovascular markings, bronchial wall thickening (47, 58%) and consolidation (28, 35%). Ground glass opacities and interstitial changes were less common in 16 (19%) and 13 (16%) children respectively. Pleural effusion (6, 7%), pneumothorax (2, 2%) and atelectasis (2, 2%) were uncommon.

24 (26%) of the children had a chest CT, mostly adolescents. The most frequent indication for CT was as a screening tool where the wait time for PCR testing was long. 22 (92%) of the CT scans were abnormal. The two most common CT changes were lower lobe ground glass opacification (21, 88%) and consolidation (14, 58%). The patterns seen on CT mirrored those described in adult studies: peripheral ground glass opacities in early stages, with ground glass with consolidation with or without interlobular septal thickening in more severe cases.

Only 3 children had lung ultrasound. One is described in the article as showing the characteristic B lines in the posterior and lateral left lung and pleural thickening. One asymptomatic child had an MRI for another reason which showed characteristic changes of COVID-19. Following this scan she was tested for COVID-19 on the recommendation of the radiologists.

paper contains numerous examples of x-rays, CTs and lung ultrasound images. The authors make several conclusions, which can be summarised in six points: In contract to adult studies, “bilateral, peripheral and subpleural ground glass opacities and/or consolidation” is not the typical chest x-ray finding of COVID-19 in children.Instead, chest x-rays of children with COVID-19 are nonspecific, frequently demonstrating peribronchovascular markings and airspace consolidation, seen in many other lower airway inflammatory disorders, viral infections and pneumonia. They therefore cannot be used to differentiate between COVID-19 and other childhood lung infections and should not be used as a screening tool for diagnosis of COVID-19 If radiographic imaging is required in symptomatic children, chest x-ray should remain the first imaging modality of choice, to assess for infection or pneumonia.Paediatric COVID-19 CT patterns are predominantly lower lobe ground glass opacity, as in adults, plus a more centrilobular or peribronchovascular pattern, not seen in adults, although it is not clear if this is directly due to COVID-19 or coinfection with other respiratory infectious agents. These findings are nonspecific and resemble other lower respiratory tract infections.CT should be reserved for complex cases or when there is clinical concern to assess for possible complications.In general, paediatric lung ultrasound image quality is superior to that in adults due to a thinner thoracic wall, however the role of lung ultrasound in children with suspected COVID-19 is unclear. The authors suggest lung ultrasound should be evaluated as a potential radiographic tool in paediatric COVID-19.

Heald-Sargent, TKociolek, LKJAMA PaediatrAge-Related Differences in Nasopharyngeal SevereAcute Respiratory Syndrome Coronavirus 2(SARS-CoV-2) Levels in Patients With Mild toModerate Coronavirus Disease 2019 (COVID-19)30 Jul 2020AmericaNorth America97Clinical - Clinical Featureshttps://jamanetwork.com/journals/jamapediatrics/fullarticle/2768952

This research letter looked at 145 patients aged 1 month to 65 years old who were symptomatic and had positive SARS-CoV-2 RT-PCR on nasopharyngeal swab at a paediatric hospital in Chicago between March 23 and April 27th, 2020. Included were 46 children aged <5 years, 51 aged 5-17 years of age and 48 adults. Cycle threshold values of RT-PCR were measured and compared across the three age groups. A significant difference was found with children under 5 having lower cycle threshold values than children aged 5-17 and adults. The older children and adults had no significant difference found in cycle threshold.

These findings are at odds with most other studies of viral loads in children, which have shown little clinically relevant difference to levels found in adults (or if anything slightly lower levels). The reason is unclear, but this study confirms what was already known, that children carry viruses in their nasopharynx which is potentially transmissible (previous studies have found culturable virus in children). To what extents this correlates with how infectious children may be remains unknown.

Pavel, AGuttman-Yasky EAllergy SARS-CoV-2 receptor ACE2 protein expression in serum is significantly associated with age29 Jul 2020New York North America48Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/abs/10.1111/all.14522
Moraleda, CTagarro, AClinical infectious DiseasesMulti-Inflammatory Syndrome in Children related to SARS-CoV-2 in Spain25 Jul 2020SpainEurope252Clinical - Clinical Featureshttps://doi.org/10.1093/cid/ciaa1042

Clusters of children with a multisystem inflammatory syndrome associated with SARS-CoV-2 infection (MIS-C) have been reported in Europe and the USA. The authors describe the epidemiological and clinical features in a case series of children with MIS-C in Spain from March 1st to June 1st, 2020. MIS-C is a potentially severe condition that presents in children with recent SARS-CoV-2 infection. Children younger than 18 years with infection due to SARS-CoV-2 and attended at 49 hospitals were included in this registry. Inclusion criteria included positivity in real-time polymerase chain reaction (RT-PCR) positive, IgM or IgG in lateral-flow rapid test, ELISA or immuno-chemiluminescence serology, or severe disease suggestive of MIS-C and recent household contact with a confirmed patient with COVID-19.

Results; In the study period, 312 patients attended 49 hospitals, and 252 participants were hospitalized. Of them, 181 (72%) were admitted due to causes directly or likely related to SARSCoV-2. The remaining 71 (28%) were admitted due to causes not related with SARS-CoV-2, but were screened and found to be infected with SARS-CoV-2. A total of 31/252 (12%) children were diagnosed as MIS-C and/or Kawasaki disease by their physicians.

 

The peak of MIS-C cases were one month after the peak of admissions for other COVID-19 related reasons and decreased afterward.

Median age and interquartile range were 7.6 [4.5; 11.5] years. A total of 30 (97%) children had microbiological or serological evidence of SARS-CoV-2 infection, and the remaining patient, an 11- year old boy with incomplete Kawasaki disease and pericardial effusion, had epidemiological household contact with a COVID-19 adult patient, his father.

The World Health Organization recently released diagnostic criteria for this condition. All the described patients fulfilled the WHO case definition for MIS-C, except for 1/31 patients (3%). Rash or bilateral non-purulent conjunctivitis, or muco-cutaneous inflammation signs were found in 21/31 (67%) patients; hypotension or shock in 15/31 (48%), features of myocardial dysfunction 25/31 (80%) consisting of pericarditis, valvulitis, arrhythmias or coronary abnormalities in 19/31 (61%); 6 (19%) additional children had only an elevation of a biochemical marker of heart dysfunction (NT-proBNP); evidence of coagulopathy (specifically, elevated D-dimers) was found in 29/30 (97%), and acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain), in 27/31 (87%). No other apparent microbial cause of inflammation as sepsis or staphylococcal or streptococcal shock syndrome was found.

One child already on oral steroids for interstitial lung disease did not fit the WHO criteria for raised inflammatory markers but was included as all other criteria were met.

Thirteen children (45%) fulfilled the criteria of complete or incomplete Kawasaki disease.  Twenty (65%) patients needed admission to the Paediatric Intensive Care Unit, and 6/31 (19%) invasive mechanical ventilation. Cardiac complications consisted of myocardial dysfunction (15/31; 48%), pericardial effusion (6/31; 19%); valvular dysfunction (9/31; 29%), arrhythmias (7/31; 23%) and coronary abnormalities (3/31; 10%, among them 1 aneurysm). Four patients (13%) had renal failure.

Two (6%) patients received Remdesivir and 7/31 (23%) Lopinavir/Ritonavir. A total of 21/31 (68%) children received corticosteroids: 19 of these received methylprednisolone (13 patients received doses of 1 to 2.5 mg/kg/day; 2 patients boluses of 8 and 30 mg/kg/day for 3 days; 4 had dosing unavailable), 20/31 (65%) patients received 2 gr/kg of intravenous immunoglobulin (IVIG) and 13/31 (42%) patients received both IVIG and corticosteroids. All but three patients received broad spectrum antibiotics.

One patient with acute leukaemia and bone marrow transplant died, and one 6-month-old patient (with Downs Syndrome) developed anterior-descendant coronary aneurysm (z-score +9). The rest recovered without sequelae.

Limitations of this study include that some cases without microbiological, serological or epidemiological links may not have been included in this registry. 

The authors conclude SARS-CoV-2 could be a relevant trigger for a delayed cytokine storm and an inflammatory condition, with potentially severe consequences. Coinfections as hMPV may be present and might play a role in triggering the immune response. It is possible that some particular patients with special features such as chronic immunosuppressive treatment influencing inflammatory markers - may have MISC but not fulfil all WHO criteria.

Conclusion The authors concluded MIS-C is a potentially severe condition that presents in some children after SARS-CoV-2 infection. Physicians should be aware of this severe condition in children during COVID-19 epidemics. More studies are necessary to clarify the physiopathology of this syndrome and its treatment. 

Comment Even when removing the child without serological evidence of COVID-19 and the child which did not meet WHO criteria in this study, 29/252 or 11.5% of hospitalised patients developed MIS-C which is significant One death was reported in a patient with leukaemia and one complication in a patient with Downs syndrome but the rest of the patients (27/29, 93%) recovered without sequelae.

Prata-Barbosa, ACunha, AJ Pediatr (Rio J)Pediatric patients with COVID-19 admitted to intensive care units in Brazil: a prospective multicenter study19 Jul 2020BrazilSouth America79Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S0021755720301923

Date, patient identification and location. Between 1st March 2020 and 31st of May 2020, 79 patients aged 1 month to 19 years consecutively admitted to 19 pediatric intensive care units in Brazil with confirmed COVID-19 (RT-PCR in 72/79 and IgM and/or IgG antibodies in the other 7/79) and were included. 10 of these patients including 5 that only had positive antibodies had multisystem inflammatory syndrome (MIS-C) .

Age: median age 4 years( range 1 to 10.3 years)

Gender:43/79( 54%) male.

Ethnicity: 58% were white,25% mixed race, 15% black and 1% Asian.

Comorbidities:32/79( 41%) had previous comorbidities with neuromuscular disease predominant (28%) and chronic respiratory disease 19% , congenital heart disease 16%, diabetes 6% , undernutrition 6% and obesity 3%.

Clinical features : most common symptom was fever 59/79 (76%), followed by cough 40/79(51% ), tachypnoea 39/79 (50% )low oxygen saturation 23/79 (29%) , runny nose 17/79 (22%), diarrhoea 16/79(21%), vomiting 16/79(21%) and red throat 3/79(4%).

In MIS-C (n=10) : presentation included Kawasaki like disease 6/10 (60%), acute cardiac dysfunction 2/10(20%), toxic shock syndrome 1/10(10%), Macrophage activation syndrome 1/10(10%).

.Radiology: 42/68 (62%) had abnormal chest radiographs with 25/42(60%) having diffuse interstitial infiltrate. Chest CT with ground glass opacities in 19/38 (50%).

Bloods: Lymphopenia in 21/59(36%) of non MIS-C group and 5/10(50%) of MIS-C group.

Inflammatory markers including ESR,CRP,LDH,D-dimer, procalcitonin and ferritin were tested in varying number of cases but mainly in MIS-C group and were elevated in most tested patients.

Outcome: 32/79(41%) needed only oxygen therapy. Invasive mechanical ventilation was needed in 14(18%) for median of 7.5 days . Comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5). Antibiotics , Oseltamivir and corticosteroids were used in 76%, 43%, and 23% respectively . The median intensive care length of stay was 5 days . There were 2 deaths (3% ) both in none MIS-C group. Age less than 1 year was not associated with a worse prognosis and patients with MIS-C had more severe symptoms, high inflammatory biomarkers but only comorbidities and chronic disease were independent predictors of severity.

Comment and Justification: this is the first study on COVID-19 in Pediatric CIU patients in Brazil which currently has one of the highest rates of infection .It has shown that the characteristics of the disease in Brazil are similar to other countries except age less than 1 year was not associated with a worse prognosis.

Kainth, MLorry, GRPediatricsEarly Experience of COVID-19 in a US Children's Hospital17 Jul 2020USANorth America65Clinical - Clinical Featureshttps://pediatrics.aappublications.org/content/early/2020/07/15/peds.2020-003186

is the first comprehensive report from a major US paediatric centre. It describes all admitted cases of COVID-19 in children and young people (CYP) aged 0-22 years, from 23 Jan to 23 April 2020. It comes from the Cohen Children’s Medical Centre, just outside New York City, which serves a relatively deprived urban population. All had SARS-CoV-2 PCR positive antigen tests.

results are broadly similar to earlier reports from China and Europe, but with some interesting detail. Of the 65 admissions, the median age was 10.3 years, but there was a bimodal distribution, with 29% being infants of < 3 months, and 48% older than 12 years. Those with an underlying medical condition were over-represented (55%).

disease severity was considered mild in 60%, moderate in 26% and severe in 14%. Mean duration of hospital stay was 3.2 days. 23 (35%) went to intensive care. The older CYP did worse than the infants: 44% of 16 previously healthy CYP required any sort of respiratory support (1 ventilated), compared to 26% of 19 infants (none ventilated).

with either immunocompromise (e.g. cancer treatment) or chronic illness (e.g. chronic lung or neuromuscular disease) were identified separately. Although over-represented in the admissions, most did well: 21% of the 14 immunocompromised required oxygen or any respiratory support (3 ventilated), as did 44% of the 16 chronically ill (5 ventilated). There was one death, a toddler with advanced neuromuscular disease. Only one developed multisystem inflammatory syndrome (MIS-C).

esity was a significant risk for admission (but not for severity): 58% of the previously healthy children were obese, more than expected for the population.

expected, the most common presenting symptoms and signs were fever (86%), upper respiratory signs (34%), lower respiratory signs (60%), anorexia (40%), myalgia (34%), abdominal pain (17%) and headache (17%). Two had seizures. Anosmia was rare (1). Interestingly, only 4/10 with known asthma presented with wheezing.,

estigation findings were similar to earlier reports. Increased CRP and white cell counts were seen, showing strong associations with disease severity. Chest X-ray abnormalities were more common than might be expected from clinical status: 21 of 43 X-rayed had abnormal findings.

iviral ‘treatment’ of some sort was given to 40%, including hydroxychloroquine, remdesevir, anakinra and corticosteroids. Outcomes so far were good: 83% discharged well, 5% discharged with ‘sequelae’, 11% still inpatients.

this is further evidence, this time from an American population, that Covid-19 is less dangerous in children than adults, and that the prognosis is good in the vast majority. This is in spite of this population’s high prevalence of underlying serious conditions, obesity, and relative deprivation.

Derespina, KRMedar, SSJ PediatrClinical Manifestations and Outcomes of Critically Ill Children and Adolescents with COVID-19 in New York City.16 Jul 2020USANorth America70Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S002234762030888X

This multicenter retrospective observational study from New York City, USA, considers admissions of patients up to 21 years of age to 9 paediatric intensive care units (PICU) in New York City between 14 March 2020 and 2 May 2020. The authors consider 70 patients who are critically ill with COVID-19 positive nasopharyngeal swabs, and present their clinical manifestations, factors associated with PICU admission, and length of hospital stay. The data collection occurred prior to the definition of the multisystem inflammatory syndrome in children, therefore this presentation is not represented in this study.

he median age of patients included is 15 (IQR 9, 19). 61.4% are male. 74.3% had at least one comorbidity. 72.9% presented with fever, and 71.4% presented with cough. Bi-lateral infiltrates were the most common chest X-ray finding (50%). CRP, procalcitonin, lactate, pro-BNP and IL-6 were elevated. ARDS was associated with significantly longer duration of admission. Back/Latino race was associated with higher probability of discharge home by day 28.

NOTE – Some duplication of data :31 out of the 70 patients who are described in this paper have been discussed in other published reports.

Gaborieau, LMadhi, FJ Clin Med 9(7)Epidemiology and Clinical Presentation of Children Hospitalized with SARS-CoV-2 Infection in Suburbs of Paris14 Jul 2020FranceEurope192Clinical - Clinical Featureshttps://www.mdpi.com/2077-0383/9/7/2227

This paper presents the demographic characteristics, presenting symptoms, co-morbidities, and clinical progression of 192 children hospitalized with either confirmed nasopharyngeal PCR for SARS-CoV-2 (157) or strongly suspected but negative PCR (35) in the Ile-de-France département, in and around Paris, during their period of lockdown, from 23/03/20 to 10/05/20. The male:female ratio was 1.3:1. Those aged <1 made up 49% of the group, and those under ≤1 month, 17.7%. 29.2% had an underlying medical condition. Twenty four (12.5%) required PIC, 19 required ventilatory support (12 by mechanical ventilation) and 3 died.

Wardell, HDixit, AJ Pediatr Infect DisSARS-CoV-2 Infection in Febrile Neonates9 Jul 2020USANorth America4Clinical - Clinical Featureshttps://academic.oup.com/jpids/article/doi/10.1093/jpids/piaa084/5869489

Case reports of 4 term male neonates presenting with fever and testing positive for SARS-CoV-2, in Boston, USA, between 17/04-06/05/20. All infections were likely to have been acquired postnatally from close household contacts. Two had co-infection (1 E. coli UTI, 1 human metapneumovirus). All made a full recovery after a brief illness but 1 was still shedding virus when last tested (20 days). One had evidence of myocardial dysfunction which was postulated to be consistent with a pulmonary immunovascular coagulopathy model. This neonate did not have any co-infection and was treated with remdesivir; claimed to be the first reported use of this drug in a neonate. The only neonate with lymphopenia was that co-infected with hMPV. Authors advise continuing to screen febrile neonates for other infections even when there has been close contact with a proven case of SARS-CoV-2 and the neonate itself is positive.

Yudan, DWenbin,GFront PediatrClinical Characteristics of Children With COVID-19: A Meta-Analysis3 Jul 2020ChinaAsia396Clinical - Clinical Featureshttps://www.frontiersin.org/articles/10.3389/fped.2020.00431/full

This is a meta-analysis of papers published between 1 January and 1 April 2020 undertaken by Chinese authors. The authors undertook a literature search and identified 121 papers worldwide, only 33 studies met the inclusion criteria and more than half these were case reports. Interestingly all the included papers were from China.

396 children in total were identified with an age range 0-17 years (mean 5.5 years), just over 60% were >5 years old, 58% were male. 6.1% of all the included children had underlying diseases. In terms of the transmission route, 86.4% of the children with COVID-19 had close contact with family members with COVID-19 and 10% tested positive for other pathogens, such as influenza virus types A and B and Mycoplasma pneumoniae.

Fever (51.2%) and cough (37.0%) were the most frequent symptom, 17.4% of the children had asymptomatic infections. Furthermore, 66.7% had pneumonia, and 19% had radiologic features of pneumonia but were asymptomatic. Five developed severe or critical illness and required intensive care. The authors report that as of April 1, 2020, two child deaths were recorded in China (a 10-month-old child and a 14-year-old boy) but do not say if these two children were part of the study cohort.

The most frequent abnormal laboratory findings were leukopenia/lymphopenia (28.9%) and increased creatine kinase (20.%). Ground glass opacities were observed on CT scans in 53.9% of the children diagnosed with pneumonia.

The nineteen case reports included 25 patients. Their mean age was 4.6 years 48% were male, and 36% were older than 5 years. 76% of these were in a family cluster. No cases had underlying diseases or other pathogenic infections. Common clinical manifestations included fever (60%), nasal congestion/rhinorrhoea (28%), cough (24%), and digestive tract symptoms (24%). In addition, 11 (47.8%) of the 25 patients had pneumonia, four (16%) were asymptomatic but with imaging features of pneumonia, and one (4%) was critically ill. No deaths were reported. Five (25%) children had GGO on their CT scan. The most prevalent abnormal laboratory finding was increased creatine kinase (58.3%), followed by increased procalcitonin (55.6%), increased LDH (44.4%), and increased white blood cells/lymphocytes (36.8%)

In their discussion the authors conclude “Children are at a lower risk of developing COVID-19 and likely have a milder disease compared with adults. However, the evidence presented in this study is not satisfactory. Further investigations are urgently needed, and our data will be continuously updated.”

Denina,MGarrazino,SPEDIATRICSLung Ultrasound in Children With COVID-191 Jul 2020ItalyEurope8Clinical - Clinical Features https://pediatrics.aappublications.org/content/early/2020/06/12/peds.2020-1157

Between March 18th and 26th 2020 8 children (age range 3 months to 10 years), 5 of whom were boys were admitted to Regina Margherita Children’s Hospital, Turin with Covid 19 respiratory tract infections. All 8 children had linear array chest ultrasound during routine medical examination. Although the number of patients analysed was small, the high concordance between radiologic and LUS findings suggested that ultrasound may be a reasonable method to detect lung abnormalities in children with COVID-19. The advantage of LUS was that the investigation could be done at the bedside, thus preventing transport of a potential infectious patient through a hospital

Wu, QXing, QPediatricsCo-infection and Other Clinical Characteristics of COVID-19 in Children 1 Jul 2020ChinaAsia74Clinical - Clinical Featureshttps://pediatrics.aappublications.org/content/early/2020/05/04/peds.2020-0961

This retrospective study from 2 hospitals in China examines the clinical and epidemiological characteristics of 74 children with confirmed SARS CoV-2 infection. Consistent with other studies, the majority of children experienced a mild course of illness with only one severe case requiring non-invasive ventilation. All recovered.

Cough was present in 32%, fever in 27% and 40% were asymptomatic at the time of testing. Lymphopenia was present in only 5% of cases. Abnormal CT imaging was observed in 50%, but only 12% showed typical changes of COVID-19.

Of those tested for other respiratory pathogens 19 of 34 had co-infection. Mycoplasma pneumoniae (16) and RSV (3) were the most common pathogens. It is not clear how these pathogens were identified. The significance of Mycoplasma in particular is not entirely clear as asymptomatic upper respiratory tract carriage in children is well recognised; similarly in interpreting serology, false

positives can be problematic.

For cases where exposure history was available 65/68 were household contacts of a confirmed adult case. There was no evidence of transmission from children to others.

This data is consistent with larger paediatrics studies demonstrating a milder course of COVID-19 in children compared with adults. Notably co-infection was not uncommon, illustrating that the presence of another respiratory pathogen should not preclude SARS-CoV-2 testing in children.

Li, JDai, XJ Med Internet ResIdentification of Symptoms Prognostic of COVID-19 Severity: Multivariate Data Analysis of a Case Series in Henan Province30 Jun 2020ChinaAsia12Clinical - Clinical Featureshttps://www.jmir.org/2020/6/e19636/pdf
Acker, KHan, JClin Pediatr (Phila)Infectious Diseases Diagnoses of Children Admitted With Symptoms of Coronavirus Disease 2019 During an Outbreak in New York City27 Jun 2020North America North America42Clinical - Clinical Featureshttps://journals.sagepub.com/doi/full/10.1177/0009922820944399?journalCode=cpja

This is a retrospective review of children with symptoms consistent with COVID-19 who were admitted at a single institution in New York City from March 12th to March 26th. Forty-two children were identified and had symptoms including fever (31), cough (21), increased work of breathing (17) and rhinorrhoea/congestion (16).

Of the 42 children, 5 (12%) had SARS-CoV-2 on nasopharyngeal swab, 15 (36%) had rhinovirus/enterovirus, 4 (10%) had human metapneumovirus 4, and 4 (10%) had bacterial infections. Overall, majority of children (25; 60%) had an infectious agent identified and were SARS-CoV-2 negative. Of the 5 children with SARS-CoV-2, two were neonates discharged within 72 hours with negative bacterial cultures, one was a 7 year old with MRSA bacteraemia and SARS-CoV-2 bacteraemia, one was a 14 year old with leukaemia who presented with fever, and the final patient had acute respiratory distress and required intubation, but was also positive for rhinovirus/enterovirus.

This small study demonstrates that even in the height of the outbreak in New York City, SARS-CoV-2 was responsible for a minority of admissions in children with respiratory symptoms. This highlights the importance of including SARS-CoV-2 in the list of differential diagnoses but ensuring appropriate investigations for viral and bacterial coinfections.

Götzinger, FTebruegge, MLancetCOVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study25 Jun 2020Europe (Austria, Belgium, Bulgaria, Croatia, Denmark, Estonia, Germany, Greece, Hungary, Ireland, Italy, Lithuania, Norway, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, and the UK)Europe582Clinical - Clinical Featureshttps://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30177-2/fulltext

This European multi centre cohort study recruited from participating centres from  the Paediatric Tuberculosis Network European Trials Groups, to look at 582 cases of paediatric (<18 years old) SARS-CoV-2 infection in 21 countries with 77 healthcare centres. Centres from five additional countries reported no SARS-CoV-2 cases at the time of the study. The breakdown of centres included 454 (78%) tertiary, 54 (9%) secondary and 74 (13%) primary healthcare providers.

Cases were collected retrospectively from known cases prior to 1st April and prospectively between 1-24th April. Diagnosis was made on RT-PCR of SARS-CoV-2 alone. The age group of the population was young, with a median age of 5 (IQR 0.5-12) and 230 (40%) under 2 years of age. Just over half were male (n=311, 53%).

Index case data from history was included, with parents being the suspected index case for 324 patients (56%) and siblings accounting for 24 cases (4%). However a large number of cases (n=234, 40%) were either from someone outside of the immediate family or of unknown transmission.

The most common symptoms patients presented in were fever (n=379, 65%) and respiratory symptoms (n=313, 54% URTI and n=143, 25% LRTI). 128 (2%) had gastrointestinal (GI) symptoms and 40 (7%) had GI symptoms without respiratory symptoms. Asymptomatic patients accounted for 16% of all cases (92). There was confirmed viral co-infection in 5% (n=29) of patients. The study did not capture laboratory values. Chest x-ray was performed in 34% (n=198) of patients. Almost half of the x-rays showed findings consistent with pneumonia and ten (5%) of ARDS.

Of the patients in the study, a quarter (145) had pre-existing medical conditions. Twenty nine patients had pre-existing respiratory conditions (asthma accounting for 16) and malignancy was known in 27 patients. The study collected data on antiviral treatments administered however numbers were small and depended on local practice.

Across the cohort 363 patients (62%) required hospital admission, 48 (8%) required ICU admission. Factors increasing risk of ICU admission (n=48) were found to be age <1 month (n=7/48, 14.6%) the presence of any pre-existing medical condition (n=25/48 52%) and presence of lower respiratory tract infection signs at time of presentation (n=35/48, 73%). Mechanical ventilation was required by 25 patients (4%) and echo was used for 1 patient. Data on treatments given included antivirals: hydroxychloroquine (n=40, 7%), remdesivir (n=17, 3%), lopinavir-ritonavir (n=6, 1%) and oseltamivir (n=3, 1%). Other immunomodulators used were corticosteroids in 22 (4%), IvIG in 7 (1%), tocilizumab (n=4, 1%), anakinra (n=3, 1%) and siltuximab (n=1).

There were 4 deaths (0.69%), all of which were in children >10 years of age. Of the four deaths, one was an out of hospital cardiac arrest.

and two had pre-existing medical conditions; one patient had a stem cell transplant 15 months prior and another patient was managed palliatively due to their pre-existing illness. By time of end study 553 patients had made a full recovery and 25 patients had ongoing symptoms.

Overall, this is one of the first multi-national European studies of SARS-CoV-2 in children. Common symptoms included respiratory and fever but gastrointestinal symptoms were present in over one fifth of cases. Although eight percent of children required ICU admission, the case fatality rate was low at 0.69%. Children at greater risk of intensive care admission had pre-existing medical conditions, were less than 1 month old, or presented with lower respiratory tract symptoms. Asymptomatic infection occurred in 16% of cases. Given that at the time of the study, there were varying practices for screening criteria, it is likely that the true proportion of asymptomatic patients is higher (and true case fatality rate lower).

Zheng, G. Guo, Y.Pediatric PulmonologyClinical Characteristics of Acute Respiratory Syndrome with SARS-CoV-2 Infection in Children in South China.24 Jun 2020China Asia52Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/full/10.1002/ppul.24921
Rossoff, JMuller, WJPediatric blood and cancerBenign course of SARS‐CoV‐2 infection in a series of pediatric oncology patients23 Jun 2020USNorth America6Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/10.1002/pbc.28504
Gonzales Cortes, Rde Carlos-Vicente, JCIntensive Care Med A multicenter national survey of children with SARS-CoV-2 infection admitted to Spanish Pediatric Intensive Care Units22 Jun 2020SpainEurope50Clinical - Clinical Featureshttps://link.springer.com/article/10.1007/s00134-020-06146-8

The Spanish Paediatric Intensive Care Society have published their findings of 50 children admitted to 47 PICUs in Spain between 1st March 2020 and 1st May 2020 with SARS-CoV-2. More than 90% of PICUs in Spain were represented in this national database. During the study period there were no deaths from SARS-CoV-2 in children admitted to PICU in the participating PICUs.

The authors divided the children into two groups: those requiring ventilation and those not requiring ventilation, to assess for different characteristics between these groups. Fourteen (28%) of the children were ventilated. Twenty-seven (54%) of the 50 children in the study had suspected PIMS-TS; these children were less likely to require mechanical ventilation (4 of the 27 required ventilation) than those without PIMS-TS. Statistical significance between the two groups was found for age (median age of 2.8 years in the ventilated group, compared to 8.6 years in the non-ventilated group); co-morbidities (12, 24%, of the 50 children had comorbidities; 8 of these were ventilated); and clinical presentation with respiratory difficulties or an ARDS-type picture.

Overall, of the 50 children, 23 (46%) had haemodynamic instability, 20 (40%) had respiratory difficulties and 1 (2%) had neurological symptoms. Shock was present in half of the children (25, 50%), renal failure in 8 (15%) and cardiac dysfunction in 17 (34%).Across the 50 children, white cell count (median 9.26, IQR 5.64-14.46), lymphocytes (median 1.02, IQR 0.42-2.59) and CRP (median 13.9, IQR 4.9-27) were not statistically different between ventilated and non-ventilated children.

These are the preliminary findings from this national registry of children with SARS-CoV-2 admitted to PICU in Spain. Further results and analysis will provide more information regarding critically unwell children with COVID-19.

Rosenzweig, JKaicker, SPediatric Blood and CancerSARS‐CoV‐2 infection in two pediatric patients with immune cytopenias: A single institution experience during the pandemic21 Jun 2020USANorth America2Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1002/pbc.28503
Hildenwall HHerleniusActa PaediatricaPaediatric COVID‐19 admissions in a region with open schools during the two first months of the pandemic21 Jun 2020SwedenEurope63Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303651/
Colmenero ITorello ABritish Journal of DermatologySARS‐CoV‐2 endothelial infection causes COVID‐19 chilblains: histopathological, immunohistochemical and ultraestructural study of 7 paediatric cases 20 Jun 2020SpainEurope7Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/bjd.19327

Anecdotally, chilblains seem to be associated with Covid-19 in children and young adults. This case series from Madrid describes 7 children (age 11-17) presenting with chilblains on their toes during the pandemic. None had underlying conditions likely to cause chilblains, and in Spain, cold weather wasn’t responsible. The chilblains looked typical, caused only minor pain and itching, and all resolved spontaneously. All had skin biopsies, which showed a variety of inflammatory and vasculitic changes on histology, typical of chilblains: they also looked specifically for SARS-CoV-2 particles in the endothelium of the dermal vessels using immunohistochemistry and electron microscopy and found the virus in all of them.

What is remarkable is that all the children were systemically well, had either mild or no respiratory symptoms; and of the 6 that had nasal and pharyngeal swabs, all were negative for SARS-CoV-2 PCR. Only 4/7 had Covid-19 positive household contacts.The implication is that children can harbour demonstrably invasive coronavirus with minimal symptoms and negative swabs. This has epidemiological as well as clinical significance.

In conclusion, the presence of SARS-CoV-2 in the endothelium of dermal vessels in skin biopsies of children and adolescents with acute chilblains confirms that these lesions are a manifestation of COVID-19. Their clinical and histopathological features are similar to those of chilblains of other aetiologies, and virus-induced vascular damage could explain their pathophysiology. Our findings support the hypothesis that widespread endothelial infection by SARS-CoV-2 could have a role in the pathogenesis of severe forms of the disease. More studies are needed to understand the reasons why previously healthy children, adolescents and young adults present

Heinz, NMartinez, MPaediatr TransplantA Case of an Infant with SARS-CoV-2 hepatitis early afterLiver Transplantation19 Jun 2020USANorth America1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/petr.13778
Xiong, XIp, PJ Pediatr.A Comparison Between Chinese Children Infected with COVID-19 and with SARS18 Jun 2020ChinaAsia244Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301144/

In this study, 244 children with SARS-CoV-2 infection from Wuhan, China are compared to 44 children diagnosed with SARS (SARS-CoV-1) in in Hong Kong in 2003. The clinical details of this series of patients from Wuhan, previously described elsewhere, are compared with those of those of children with SARS-CoV-1. Overall children with SARS-CoV-2 were younger than those with SARS-CoV-1 (median age 82 montsh vs 160 months). Compared with SARS-CoV-1 patients, children with SARS CoV-2 were less likely to have symptoms (20.9% asymptomatic vs 0% of SARS-CoV-1), including fever (40.2% vs 97.7%), myalgia (37.6% vs 0.8%), and chills (32.6% vs 3.7%).

Fewer children with SARS-CoV-2 required supplemental oxygen (4.7% vs 18.6%) and few in either cohort required mechanical ventilation (1.6% vs 2.3%). A single death occurred in a patient with SARS-CoV-2 (a 10 mo with intussusspection) and no cases of PIMS-TS / MIS-C were identified amongst the 244 SARS-CoV-2 infected children from Wuhan.

The most striking difference is the milder clinical illness and relative lack of symptoms in children with SARs-CoV-2 compared with those with SARS-CoV-1. The lack of asymptomatic infections in SARS-CoV-1 is also notable, similar to findings in adults. Whilst the role of asymptomatic patients in the spread of SARS-CoV-2 is unresolved, the milder clinical illness in the majority of patients along with the demonstrated earlier peak in viral shedding relative to symptom onset and resultant role of pre-symptomatic transmission are likely major reasons for the continuing widespread transmission of SARS-CoV-2, where the outbreak of SARS-CoV-1 in 2003 was more readily contained.

Del Barba, P.Barera, G.Pediatr PulmonolCOVID-19 cardiac involvement in a 38-day old infant18 Jun 2020ItalyEurope1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/full/10.1002/ppul.24895

First (single) case report of an infant with biochemical and echocardiographic evidence of mild cardiac involvement due to SARS-CoV-2 infection. The 38 day old male infant presented to hospital on 27/03/20. Neither the centre nor the country is identified but is likely to be in Italy. Pregnancy had been unremarkable. No delivery details given. Baby was formula fed. Both mother and father were +ve for SARS-CoV-2. He presented with a fever of 37.6oC and rhinitis but no respiratory distress and did not require oxygen therapy. Nasal and nasopharygeal swabs were +ve for SARS-CoV-2. Haemoglobin, lymphocyte count, CRP, ESR, electrolytes, liver transaminases, INR and PTT were normal. Abnormal results: LDH “mildly increased”, platelet count 525,000/μl, procalcitonin 3.28ng/ml, troponin T 8.2ng/dl, creatine kinase-MB 9.8μg/L, D-dimer 13.3 μg/ml, pro-brain natriuretic hormone 208pg/ml, fibrinogen 1.28g/L. CXR showed increased bronchovascular markings but no parenchymal changes (CT not done). A resting heart rate of 140bpm and a transient peak rate of 200bpm were the only cardiac signs (serial ECGs and 24hr recording). First echocardiogram showed no abnormalities but cardiac MR scan showed a “minimal amount” of pericardial effusion with no myocardial edema. Follow up echo 3 days after the first confirmed a 2mm effusion. A panel of other viruses linked to pulmonary and/or cardiac problems in infants was negative. He required no treatment and was discharged after 14 days. Swabs were -ve 21 and 22 days after presentation.

Meethal, LBKociolek, LKj.pedsSARS-CoV-2 Infection in Infants Less than 90 Days Old17 Jun 2020USANorth America18Clinical - Clinical Featureshttps://www.jpeds.com/article/S0022-3476(20)30750-2/fulltext
Ekbatani, M. S.Mamishi, S. British Journal of Biomedical Science Atypical and novel presentations of Coronavirus Disease 2019: a case series of three children.16 Jun 2020Iran Asia3Clinical - Clinical Featureshttps://www.tandfonline.com/doi/full/10.1080/09674845.2020.1785102?scroll=top&needAccess=true
Li, YLi, Jpaediatric pulmunologyImmune-related factors associated with Pneumonia in 127 children with Coronavirus Disease in 2019 in Wuhan.16 Jun 2020chinaAsia127Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1002/ppul.24907
Stewart, DStojanovic, JLancet. Child & adolescent healthRenal dysfunction in hospitalised children with COVID-1915 Jun 2020UKEurope52Clinical - Clinical Featureshttps://www.thelancet.com/pdfs/journals/lanchi/PIIS2352-4642(20)30178-4.pdf
Ranabothu, SVeerapandiyan, AActa Paediatr.Spectrum of COVID‐19 in Children15 Jun 2020USANorth America1353Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/apa.15412
Lanyon, NPeters, MArch Dis ChildhCritical paediatric COVID-19: varied presentations but good outcomes15 Jun 2020United KingdomEurope11Clinical - Clinical Featureshttps://adc.bmj.com/content/early/2020/06/28/archdischild-2020-319602

In this letter from Great Ormond Street Hospital for Children, London, 24 children, who tested positive for Covid-19, were admitted to the intensive care unit between 26th March 2020 and 31st May 2020. Thirteen of these had PIMS-TS. This letter describes the clinical features of the remaining 11.

These 11 had a median age of 5 years (range 0.4-11), 9 were boys, 9 had pre-existing medical conditions, and 4 came from the BAME community. The primary presenting feature was cough 6, apnoea 3, fever 10, gastrointestinal 6 and seizures 3 In all 11 inflammatory markers were raised, median ferritin 898 (range 254-1991), CRP 158 (27-449), LDH 1594 (802-4264) D-Dimer 158 (27-449). 4 children fulfilled the criteria for paediatric acute respiratory distress syndrome, the remaining 7 were admitted to PICU for other reason than respiratory failure. A variety of different forms of respiratory support were provided, invasive mechanical ventilation 9, prone position 4, inhaled pulmonary vasodilators 4, HFOV 2 and ECMO none. 5 children received remdesivir and 6 prophylactic anticoagulation.

All 11 children survived to hospital discharge. The authors conclude “While children can present to PICU with a pattern of illness similar to adult COVID-19 disease this is rare and three quarters of them had risk factors for respiratory infection. A larger number were found to be SARS-COV-2 coincidentally.”

Kanthimathinathan, KJyothish, DHospital PediatricsCOVID-19 - a UK Children's Hospital Experience15 Jun 2020UKEurope45Clinical - Clinical Featureshttps://hosppeds.aappublications.org/content/hosppeds/early/2020/06/06/hpeds.2020-000208.full.pdf
Pan, YZhang, LJIDEpidemiological and Clinical Characteristics of 26 Asymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Carriers15 Jun 2020ChinaAsia26Clinical - Clinical Featureshttps://academic.oup.com/jid/article/221/12/1940/5823633
Lee,HLytrivi,IPediatr TransplantVarying Presentations of COVID-19 in Young Heart Transplant Recipients:a Case Series15 Jun 2020United States of AmericaNorth America4Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/abs/10.1111/petr.13780?af=R

This is a peer reviewed prepublication case report on the experience of Covid-19 among a population of young heart transplant patients from a tertiary centre, Columbia University Irving Medical Centre, New York.

Period Covered: first 3 months of the New York Covid pandemicHospital/Region Covered: the tertiary transplantation programme is one of the largest in the USA covering “hundreds” of patients.

Identification of Patients: 4 patients under the care of the hospital for heart transplantation are included. Case 1 was admitted after referral from secondary care with Covid symptoms and an oxygen requirement.. Cases 2 and 4 presented from home and case 3 was diagnosed during a planned admission for heart biopsy.

Age/Gender: there is a wide age range: case 1 (F)15 years, case 2 (F)25 years, case3 (M)13 months, case 4(F) 29 months.

Comorbidities and immunosuppression: The authors highlight the questions of whether the comorbidities (including immunosuppression) associated with heart transplantation lead to worse outcomes with Covid infection? Also whether immunosuppression has a protective or aggravating effect on outcome and how regimes should be managed?

Two patients (1 and2)also had renal transplants. Case 2 had connective tissue disease (elevated IL-2).

All patients were on various combinations of immunosuppressants (1,2 and 3 on steroids).In only one case (1) was this withheld during infection because of neutropenia.Clinical Features: 3 patients (1,2,3) had symptoms of acute Covid-19 and were nasal/nasopharyngeal positive. Case 1 required supplemental oxygen but no other treatment for 3 days and was then discharged.Cases 2 and 3 did not require admission. Cough: 3/3. Fever: 3/3.Sore throat: 1/3. Abdominal pain: 1/3. All remained well on follow up.

Patient 4 is likely to have had Covid-19 4 weeks prior to admission (symptoms and family history). She presented with a probable post Covid anaemia and hepatitis. She had a rash (acral papular) She was negative on nasal and hepatic Covid assay. Her liver biopsy was consistent with viral hepatitis. Her Covid serology was positive and other viral hepatitis serology negative. She received a blood transfusion

Reported Imaging: CXR:1/4. Normal. Cardiac echo:2/4. No deterioration.

Laboratory: Case1: WCC low 1460/ul, neutropenia (800/ul). ?secondary to immunosuppression or Covid. Elevated inflammatory markers: CRP, ferritin. D-dimer, pro- BNP elevated.

Case 2: no report. Case 3: normal FBC, CRP and LFTs.

Case 4: Hb 6.2 g/dl. Peak ALT elevated 1807 U/L. Peak AST 1070 U/L.

Comment: The centre maintains surveillance (telehealth) of most of it’s patients. Despite possible risk factors of comorbidities and immunosuppression only 4 cases presented. In the acute cases the illness was either mild (2,3) or moderate (1). This is the first report from a paediatric transplant centre and it will be necessary to examine the experience in other centres worldwide.

Case 4 developed hepatitis, anaemia and a rash 4 weeks after probable Covid infection. It is possible that this was Covid related. Viral hepatitis has been reported in a child post liver transplant with acute Covid infection.

Colonna, C.Gelmetti, C.Pediatric dermatologyChilblains in children in the time of Covid‐19: new evidence with serology assay13 Jun 2020ItalyEurope8Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/pde.14269
Kesici,SBayracki,BESCFulminant COVID 19 related Myocarditis in an infant12 Jun 2020TurkeyAsia1Clinical - Clinical Featureshttps://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa515/5856627

Clinical Features: 2 year old previously healthy male in contact with Covid19, hospitalized with nausea, vomiting and lethargy. On Day 2 of admission deteriorated with Respiratory distress, filiform pulse and blood pressure was not measurable. There was hepatomegaly. Child was intubated in PICU, while preparing for ECMO went into cardiac arrest. 30 minutes of CPR was performed. During ECMO biopsy of myocardium was taken.

Radiology: Initial CXR – bilateral interstitial infiltrates. Day 2: CXR Cardiomegaly with pleural effusion. ECHO: Severe heart failure

Bloods: Initial bloods negative for inflammatory markers but Troponin was elevated 30 times normal on Day 2.

PCR for viruses were negative including RT PCR for Sars_COV_2 Myocardial Biopsy showed local inflammation, Positive for RT_PCR for COVID 19

Conclusion: Single case report showing the effect of COVID 19 causing heart failure secondary to myocarditis without Kawasaki like syndrome

Zeng, QLYu, ZJTransbound Emerg DisClinical course and treatment efficacy of COVID-19 near Hubei Province, China: a multicentre, retrospective study12 Jun 2020ChinaAsia3Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/tbed.13674
Jafari, RJavanbakht, MTravel Med Infect DisA 6 months old infant with fever, dyspnea and poor feeding, diagnosed with COVID-1911 Jun 2020IranMiddle East1Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S1477893920302799
Marhaeni, WR. S. Mapianto,Indian J PediatrThalassemic Child Presenting with Anosmia due to COVID-19.9 Jun 2020Indonesia Asia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7281692/pdf/12098_2020_Article_3370.pdf
González-Dambrauskas, SKarsies, TPediatricsPediatric Critical Care and COVID199 Jun 2020InternationalInternational17Clinical - Clinical Featureshttps://pediatrics.aappublications.org/content/pediatrics/early/2020/06/05/peds.2020-1766.full.pdf

In preprint, González-Dambrauskas et al describe 17 children with COVID-19 admitted to international PICUs in Chile, Colombia, Italy, Spain and USA, in April 2020. These are interim results from the CAKE (Critical Coronavirus And Kids Epidemiologic) Study, recruiting between April and December 2020 from almost 60 PICUS in 20 countries. As well as describing the clinical details of each child in detail, this paper also describes four children with myocarditis associated with covid-19.

The 17 children predominantly presented with cough and fever (53% had cough, 76% had fever). Comorbidities were common in 71% of children, including underlying respiratory, cardiac, renal, liver or neurological disorders. Six children (35%) had gastrointestinal (GI) symptoms at presentation.

Of the four children with myocarditis, all were based in Europe, none had previous cardiac disease, and all presented with fever and GI symptoms. One also had a rash and conjunctivitis. These children all developed myocarditis early in their clinical picture, with average duration of symptoms prior to presentation of 3.5 days. All four children received IVIG. Three of these children also required inotropic support; one child also developed ARDS and acute kidney in addition to myocarditis, requiring non-invasive ventilation but not renal replacement therapy. None of the four children with myocarditis required mechanical ventilation. All four children survived to discharge home, with a mean hospital length of stay of 13.5 days.

Cen YLiu Y HClin Infect Dis.Risk factors for disease progression in patients with mild to moderate coronavirus disease 2019 - a multi-centre observational study.8 Jun 2020ChinaAsia5Clinical - Clinical Features https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30341-4/fulltext
MAK, PQKwan, MPediatr.Infect.Dis.J.Anosmia and Ageusia : not an uncommon presentation of COVID-19 infection in children and adolescents.8 Jun 2020USANorth America3Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/.
Trogen, BShust, GPed. Infectious Disease J.COVID-19-Associated Myocarditis in an Adolescent8 Jun 2020USANorth America1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/COVID_19_Associated_Myocarditis_in_an_Adolescent.96126.aspx

This case report details the admission to PICU of a 17-year-old obese male (BMI 30kg/m2) with spondylolysis and a distant history of asthma (not requiring medication for > 5 yrs) who presented to a hospital in New York City during the third week of April with septic shock, after a week’s history of fever, GI symptoms and neck pain.

Clinical features: 7 day history of fever and neck pain and a 6 day history of diarrhoea and vomiting (non-bloody, non-bilious). No neck stiffness, headache, photophobia or respiratory symptoms. At presentation he was febrile, tachycardic and hypotensive (79/66 mmHg) with diffuse abdominal pain. His cardiovascular status remained labile after initial fluid resuscitation and he was admitted to PICU.

Initial bloods: Lymphocytes 0.9 x 103/L, CRP 167 mg/L, ferritin 1275 ng/mL, D-dimer 1218 ng/mL, initial Troponin I level 2.97 ng/mL rising to 6.17 ng/mL 2 hrs later, brain natriuretic peptide 2124 pg/mL, sodium 128 mmol/L, creatinine 1.25 mg/dL, creatine kinase 761 U/L, LDH 346 U/L, INR 1.5, IL-6 28 pg/mL

Microbiology: Nasopharyngeal swab RT-PCR SARS-CoV-2 positive. Other respiratory and GI pathogen PCRs negative, including enterovirus, adenovirus, CMV, EBV, HHV-6, parvovirus B19.

Radiology: Abdominal USS essentially normal. CXR: low lung volumes, normal cardiothymic silhouette and mild, hazy ground glass opacities at the lower lobes bilaterally.

ECG: T-wave inversion particularly in inferior leads.

Cardiac imaging: Initial transthoracic echocardiogram: LV ejection fraction mildly depressed with no obvious intracardiac clots or pericardial effusion. Cardiac MRI: normal sized LV & RV, LVEF 40%, RVEF 39%, area of mid-wall late gadolinium enhancement at inferior LV-RV junction corresponding to area of increased T2 signal as well as an area of hypokinesia, consistent with myocarditis.

Treatment in PICU: Blood pressure normalised on day 1, but remained febrile and tachycardic until day 4. Required 2 days of oxygen via NC. Received anticoagulation, paracetamol/ibuprofen and 48 hrs of piperacillin/tazobactam until blood cultures reported negative. No other anti-inflammatories or IVIg given. Initially started on hydroxychloroquine which was stopped on day 3 when serial ECG demonstrated prolonged QTc interval not present initially. Serial Troponin I and BNP levels normalised by discharge.

Outcome: Discharged on day 5 with 2 week course of anticoagulation (apixaban). Echocardiogram at follow-up one week after discharge demonstrated normal ejection fraction (59%) with qualitatively improved function. However, tissue Doppler imaging signals of the mitral valve annulus were still abnormally diminished with low global longitudinal strain rate, consistent with residual myocardial dysfunction. Repeat ECG showed persistent T-wave inversion in lead III.

The authors conclude with a discussion of the possible mechanisms of cardiac injury secondary to COVID-19, including viral entry via the ACE2 receptor causing direct damage to myocardiocytes, immune-mediated injury secondary to cytokine release or T-cell dysregulation, microvascular damage, endothelial shedding/dysfunction, hypoxia-mediated injury and abnormal coagulation, including DIC, increasing the risk of thrombosis and ischaemic events.

Du, WQ. LiJ Infect Public HealthPersistence of SARS-CoV-2 virus RNA in feces: A case series of children7 Jun 2020ChinaAsia10Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S1876034120304913
Chen, YXiao, XJ Infect Public HealthRe-evaluation of retested nucleic acid-positive cases in recovered COVID-19 patients: Report from a designated transfer hospital in Chongqing, China7 Jun 2020ChinaAsia4Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275981/
Foster, CCampbell, JJ Pediatric Infect Dis Soc.Coronavirus Disease 2019 in Children Cared for at Texas Children’s Hospital: Initial Clinical Characteristics and Outcomes6 Jun 2020USANorth America57Clinical - Clinical Featureshttps://academic.oup.com/jpids/advance-article/doi/10.1093/jpids/piaa072/5854294
Xing, CXu, ZWorld J Clin Cases Serial computed tomographic findings and specific clinical features of pediatric COVID-19 pneumonia: A case report6 Jun 2020ChinaAsia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7281042/
Li, C. Wu, B Medicine A 3-month-old child with COVID-19: A case report.5 Jun 2020China Asia1Clinical - Clinical Featureshttps://journals.lww.com/md-journal/fulltext/2020/06050/a_3_month_old_child_with_covid_19__a_case_report.92.aspx
Sun, D., XLiu, Z., SWorld Journal of Pediatrics SARS-CoV-2 infection in infants under 1 year of age in Wuhan City, China5 Jun 2020ChinaAsia36Clinical - Clinical Featureshttps://link.springer.com/article/10.1007%2Fs12519-020-00368-y
Gorkem,SCetin,BDiagn Interv RadiolCOVID-19 pneumonia in a Turkish child presenting with abdominal complaints and reversed halo sign on thorax CT5 Jun 2020TurkeyEurope1Clinical - Clinical Featureshttps://www.dirjournal.org/en/covid-19-pneumonia-in-a-turkish-child-presenting-with-abdominal-complaints-and-reversed-halo-sign-on-thorax-ct-167964

This is a case report of a 15 year old girl with Covid-19 from Turkey in an Epublished letter ahead of print with an early description of the “reversed halo sign”(RHS) on chest CT scan in. RHS is described as a central ground glass opacity (due to septal alveolar inflammation) surrounded by denser granulomatous airspace consolidation in the shape of a crescent or ring. It was identified in adult Covid -19 patients in early studies from Wuhan.

The patient presented with abdominal pain (epigastric tenderness). She had no respiratory symptoms and was apyrexial. Covid-19 was identified on nasopharyngeal swab. WCC 4.01x109, lymphocytes 1.92x109, CRP 1.6 mg/l rising to 10 mg/l after five days. Oxygen saturation remained above 95% in air.

Initial abdominal CT identified bilateral patchy alveolar infiltrates in the lower lobes and so an unenhanced low-dose thorax CT was performed. This identified multi focal RHS lesions within bilateral upper, middle and lower lobes. There were multiple multisegmental peripherally located alveolar infiltrations and scattered ground glass opacities.

The patient received hydroxy chloroquine. Interestingly, she did not develop any respiratory symptoms, making an uneventful recovery and was discharged after 8 days.RHS is a distinctive sign on chest CT. As well as occurring in pneumonia (including community acquired pneumonia) it can also be associated with fungal infections, immunosuppression, pneumocystis, TB, sarcoidosis, pulmonary neoplasms and pulmonary infarction. Therefore it can pose diagnostic challenges and management is guided by the clinical history. Although RHS is recognised in the adult Covid-19 literature this is a first report in a paediatric patient.

Mohammadi, A Mirza‑Aghazadeh‑Attari, MJpn J RadiolClinical and radiological characteristics of pediatric patients with COVID-19: focus on imaging findings4 Jun 2020IranMiddle East27Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293432/
Kerber, AYoussef, MIntnl J of DermatologyChilblains-like dermatologic manifestation of COVID-19 diagnosed by serology via multidisciplinary virtual care4 Jun 2020USANorth America1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/10.1111/ijd.14974
Lin, EShah, AJAMA SurgeryIncidence of COVID-19 in Pediatric Surgical Patients Among 3 US Children’s Hospitals4 Jun 2020USANorth America12Clinical - Clinical Featureshttps://jamanetwork.com/journals/jamasurgery/fullarticle/2766924
Zachariah, PSalman, LJAMA PediatricsEpidemiology, Clinical Features, and Disease Severity in Patients With Coronavirus Disease 2019 (COVID-19) in a Children’s Hospital in New York City, New York3 Jun 2020USANorth America50Clinical - Clinical Featureshttps://jamanetwork.com/journals/jamapediatrics/fullarticle/2766920
Wu, HXiang, YJAMA Netw OpenClinical and Immune Features of Hospitalized Pediatric Patients With Coronavirus Disease 2019 (COVID-19) in Wuhan, China3 Jun 2020ChinaAsia157Clinical - Clinical Featureshttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766670

In this retrospective case series from Wuhan, China, the clinical and immunological characteristics of children admitted to hospital with confirmed SARS-CoV-2 infection are examined. Details are provided for the 148 children with mild or moderate disease.

The median age was 84 months (IQR 18-123). Fever (40.5%) and cough (44.6%) and vomiting or diarrhoea (21.6%) were the most common symptoms. SARS-CoV-2 PCR became negative at a median of 7 days (IQR 4-11 days).

Lymphopenia was present in only 4.5% of patients; CD 4 lymphopenia in 1.9%. Elevation in CRP (32.4%) and procalcitonin (47.3% elevated; median 0.05 (IQR 0.04-0.08)) was observed in fewer than half of patients. Liver transaminases and LDH were significantly higher in moderate versus mild cases but the vast majority of levels fell within normal range.

Levels of inflammatory cytokines including IL2, IL6, TNG-a and IFN.y were largely normal; the authors note that one patient with severe disease had elevated IL-6 (3869 pg/mL). IL-10 was increased in 14%.No deaths occurred amongst mild and moderate cases and all 148 patients were discharged.

In this large case series of children with mild or moderated SARS-CoV-2 infection, laboratory measures of inflammation were largely normal. Specifically the significant elevations in IL-6, D-dimer, and ferritin characteristic of severe COVID-19 in adults and also PIMS-TS / MIS-C in children were absent in these milder cases. The authors postulate that the relative preservation of CD4 T-cells and the higher levels of IL-10 compared with adults with severe COVID-19 may indicate these as important components of a protective immune response.

As yet our understanding of the drivers of variation in individual immune response to SARS-CoV-2 remains incomplete.

Parri,NLazzerini,MEur J Pediatr Characteristic of Covid-19 infection in paediatric patients: early findings from two Italian Pediatric Research Networks 3 Jun 2020ItalyEurope130Clinical - Clinical Features https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269687/pdf/431_2020_Article_3683.pdf

This study is published as a short communication describing the clinical presentations and outcomes in children with identified Covid-19 in 61 centres in Italy between 3rd and 26 March 2020.Study Design: A retrospective study coordinated by the CONFIDENCE and COVID-19 Italian Paediatric Study Network’s involving 53(86.9%) hospitals and 8(13.1%) outpatient centres in 10 mainly northern regions. All children (0-18 years) diagnosed positive on screening and testing for Covid-19 by nasal/nasopharyngeal RT-PCR assay were entered into the study. Clinical, laboratory and imaging data was collected on standardised forms.

Study Population: 130 children and adolescents recruited (112 hospital;18 outpatient). <2 years 41 (31.5%), 2-9 years 35 (26.9%)’10-17 years 45 (34.6%). Male 73 (56.2%). Female 57(43.8%) p=0.47.Comorbidities 34 (26.2%) most frequent cardiovascular, respiratory and neuromuscular. No information on ethnicity. One patients data unobtainable.

Disease Severity: The majority of subjects were categorised as being asymptomatic or having mild disease 98/130 (75.4%). 11 (8.5%) were moderate severity, 11 severe and 9 (6.9%).critical. 75 (57.7%)were hospitalised with 15.(11,5%)needing respiratory support (5 needing oxygen, 2 non invasive ventilation and 2 mechanical ventilation). 9 cases were admitted to ICU with 6 being less than 6 months. 3 of the latter were less than 2 months and did not require respiratory support. Children less than 6 months had an increased risk of critical disease than older children: 6/35 (17.1%) vs 3/86 (3.5%) p=0.34. OR 5.6 CI 1.3 to 29.1.

Symptoms: Common symptoms were fever 67(51.5%), dry cough 38(29.2%) and productive cough 16(12.3%). Other symptoms were rhinorrhoea25(19.2%), respiratory distress 17(13%), vomiting 15(11.5%);diarrhoea 10(7.6%); sore throat 9(6.9%). Thoracic pains (3%), somnolence, febrile convulsions (1.5%) and lower limb pains (1.5%) were reported as novel symptoms.

Oxygen saturation at presentation: 91-92% 1(0.8%). <90 1(0.8)

Radiology: 41 (31.5%) of children had CXRs. These were normal in 15 (36.6%). The commonest abnormalities were ground-glass opacities in 17 (41.5%). Focal consolidation was seen in 4 (9.8%). Laboratory: 71 children were reported to have had laboratory tests. The authors report leukopenia (WCC %<5.5x109) and lymphopenia (<1.2x109) in 7/19 patients and 3/19 patients, respectively. They report elevation in aspartate transaminase >50U/l in 11/60 (18.3%) and alanine tranasaminase >45U/l in 8/68 (11.8%).

Outcomes: There were no deaths and all children were reported to have recovered. Comment: The study obtained data on all but one child found Covid-19 positive in this largely hospital based population. The authors acknowledge that there is a bias toward more ill patients with their population than community studies and this may explain the 57.7% admission rate. Also this is reflected in the amount of comorbidity. However, the majority of patients were either asymptomatic or had mild disease and small numbers required respiratory support or ITU. The authors identify the increased likelihood of critical disease in those less than 6 months and their being the majority of ICU cases. They also comment on new presenting symptoms (thoracic pain, somnolence, febrile convulsions and lower limb pains).

Pandey UDien Bard JMedRxIVPediatric COVID-19 in Southern California: clinical features and viral genetic diversity2 Jun 2020CaliforniaNorth America35Clinical - Clinical Featureshttps://www.medrxiv.org/content/10.1101/2020.05.28.20104539v2.full.pdf

A study of 35 children age range 18 days to 18.5 years (median12.5), 57% of whom were boys, seen over an 8 week period in Southern California. Patients were identified by nasopharyngeal swabs submitted to Los Angeles Children’s Hospital between 11 March 2020 and 11 May 2020. 37% were hospitalised with a median inpatient stay of 4 days. Symptoms were diverse with fever and cough being the most common, 1/3 were symptomless. Whole genome sequencing was undertaken on Covid-19 samples. There was an association between disease severity and viral load. Children < 5 years age had a higher viral load and all were symptomatic. There was limited variation in the viral genome though a calculated evolutionary rate was like other RNA viruses. No correlation was identified between disease severity and genetic variation.

Frauenfelder, CBamford APediatricsInfant With SARS-CoV-2 Infection Causing Severe Lung Disease Treated With Remdesivir1 Jun 2020United KingdomEurope1Clinical - Clinical Featureshttps://pediatrics.aappublications.org/content/early/2020/06/16/peds.2020-1701
Escalera-Antezana, JP Rodríguez-Morales, AJLe Infezioni in MedicinaRisk factors for mortality in patients with Coronavirus Disease 2019 (COVID-19) in Bolivia: An analysis of the first 107 confirmed cases1 Jun 2020BoliviaInternational9Clinical - Clinical Featureshttps://www.infezmed.it/media/journal/Vol_28_2_2020_15.pdf
Manzoni, P Polastri, RoThe Pediatric Infectious Disease Journal: Uncommon Presentation of Coronavirus Disease 2019 Infection in a Child 1 Jun 2020italyEurope1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Citation/9000/Uncommon_Presentation_of_Coronavirus_Disease_2019.96134.aspx
Jones, B. A. ." . Slater, B. J. Journal of Pediatric Surgery Case ReportsNon-operative management of acute appendicitis in a pediatric patient with concomitant COVID-19 infection31 May 2020USANorth America1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261356/
Alsofayan, YAssiri, AJ Infect Public HealthClinical characteristics of COVID-19 in Saudi Arabia: A national retrospective study31 May 2020Saudi ArabiaMiddle East74Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S1876034120304925
Valente, PBuzzonetti, LJournal of AAPOSOcular manifestations and viral shedding in tears of pediatric patients with coronavirus disease 2019: a preliminary report30 May 2020ItalyEurope27Clinical - Clinical Featureshttps://jaapos.org/article/S1091-8531(20)30115-4/fulltext?rss=yes

27 paediatric patients were identified between 16/03/2020 – 15/04/2020, from Bambino Gesù Children’s Hospital, Rome, Italy. It was not clear how patients were identified/recruited. The mean age was 84 months (range=8 days to 210 months). 74% were male (n=20); 26% were female (n=7).

Clinical features present: - Cough and/or dyspneoa = 15 patients (56%); - Vomiting and/or diarrhoea = 8 patients (30%); - Ocular manifestations consistent with viral conjunctivitis = 4 patients (15%);

In the abstract it states that "At admission, all patients showed ocular manifestations", however there is no other reference to further information in the paper.Radiology/bloods: N/a

Other investigations: Nasopharyngeal swab to COVID-19 tested positive in all 27 patients. Of the 4 patients with apparent viral conjunctivitis, 1 patient resulted positive for SARS-CoV-2 on RT-PCR from conjunctival swab. Of the other patients (n=23), two more patients had positive findings for SARS-CoV-2 in their conjunctival swab without developing clinical signs of conjunctivitis.Outcomes: 27 (100%) discharges. Other salient features: Some preliminary evidence to suggest that SARS-CoV-2 shedding is low in eye secretions/tears.

Olisova, OYShnakhova, LMDermatol TherCutaneous manifestations in COVID‐19: a skin rash in a child30 May 2020RussiaEastern Europe and Northern Asia1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/dth.13712
Cai, JHe, GJ Med VirolClinical features and the treatment of children with COVID-19: a case series from Wenzhou, China30 May 2020ChinaAsia3Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/full/10.1002/jmv.26092
Kakuya, FKinebuchi, TJapanese Journal of Infectious DiseasesThe first pediatric patients with coronavirus disease 2019 (COVID-19) in Japan; The risk of co-infection with other respiratory viruses29 May 2020JapanAsia3Clinical - Clinical Featureshttps://www.jstage.jst.go.jp/article/yoken/advpub/0/advpub_JJID.2020.181/_pdf
Zhao, WZhang, FClin PediatrCharacteristics of Children With Reactivation of SARS-CoV-2 Infection After Hospital Discharge28 May 2020ChinaAsia14Clinical - Clinical Featureshttps://journals.sagepub.com/doi/full/10.1177/0009922820928057

In this study from Beijing, China, serial nasopharyngeal swabs were performed on children discharged between January 21st and April 18th 2020 following hospital admission with confirmed SARS-CoV-2 infection. Criteria for hospital discharge included clinical improvement and 2 negative RT-PCR tests for SARS-CoV-2 on consecutive nasopharyngeal swabs. Follow up swabs were performed fortnightly following discharge; the authors report on children with subsequent positive RT-PCR on follow up.

In total 14 children were followed, 7 of whom had a subsequent positive SARS-CoV-2 PCR result, none of whom had significant symptoms at the time (one with a temperature of 37.5). There were no significant clinical or laboratory differences between the group with subsequent positive tests compared with those who remained negative.

The authors refer to those who have subsequent positive SARS-CoV-2 PCR as having "reactivation" of infection. This is a misnomer as the persistent shedding of viral RNA has been well recognised in adult studies. This includes a large cohort of over 200 patients from Korea with positive tests following negative PCR results, similar to the children in this study. Importantly no onward transmission from these "re-positive" cases was found amongst 790 contacts in the Korean cohort, suggesting the viral RNA detected in patients with prolonged shedding is not viable. Indeed in a recent in vitro study including 90 SARS-CoV-2 PCR positive samples, only samples taken within 8 days of symptoms onset were capable of infecting cells. This is in keeping with contact tracing data suggesting peak transmissibility occurs before and immediately after symptom onset with limited transmission beyond 5 days of symptom onset.

The likely explanation of the "reactivation" described here is prolonged shedding of non-viable viral RNA with an interim "false negative" samples prior to hospital discharge. Given the available data, it is unlikely that these "re-positive" discharged patients represent an infection risk to others

Oualha, MRenolleau, SArchives de PédiatrieSevere and fatal forms of COVID-19 in children28 May 2020FranceEurope27Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S0929693X20301172

The 27 children described here constitute the biggest series to date of children sick enough to need high dependency care during active COVID infection. The criteria for admission were oxygen requirement > 1L/min or underlying disease.

The cohort of 27 were admitted within days of onset of first symptoms and 24 were positive for COVID-19 by PCR of nasal swabs. This is consistent with active virus, rather than PIMS-TS, the Kawasaki like post-COVID syndrome.

24 had respiratory disease, mostly with radiological or CT findings consistent with COVID. 6 had cardiovascular disease and 4 renal problems.

9 required invasive ventilation with median duration 5 days. 10 received non-invasive ventilation and 23 were treated with oxygen. 4 received catecholamines, one ECMO and one renal replacement therapy. The median length of hospital stay was 6 days.

Mean laboratory findings in the group were of elevated CRP, procalcitonin, fibrinogen and D-dimers, consistent with an inflammatory and prothrombotic state. Neutrophil and lymphocyte counts were normal. T cell subsets and cytokine levels were not measured. 70% had underlying conditions, but the spectrum was different from adult experience, with neurological and respiratory problems or sickle cell disease being most common.Three of the five who died had previously been in good health. A teenage girl whose clinical course was suggestive of the cytokine storm seen in adults died within hours of admission. A teenage boy and a 6 year old girl co-infected with other pathogens both died after long PICU stays.

This description confirms that severe illness is rare in children with COVID and shows that even those admitted for HDU care had a shorter illness and better prognosis than that seen in adults. Nonetheless, occasional children do suffer a prolonged illness with multi-organ dysfunction.

Zhao, WZhang, FClin PediatrCharacteristics of Children With Reactivation of SARS-CoV-2 Infection After Hospital Discharge 28 May 2020ChinaAsia15Clinical - Clinical Featureshttps://journals.sagepub.com/doi/full/10.1177/0009922820928057

In this study from Beijing, China, serial nasopharyngeal swabs were performed on children discharged between January 21st and April 18th 2020 following hospital admission with confirmed SARS-CoV-2 infection. Criteria for hospital discharge included clinical improvement and 2 negative RT-PCR tests for SARS-CoV-2 on consecutive nasopharyngeal swabs. Follow up swabs were performed fortnightly following discharge; the authors report on children with subsequent positive RT-PCR on follow up.

In total 14 children were followed, 7 of whom had a subsequent positive SARS-CoV-2 PCR result, none of whom had significant symptoms at the time (one with a temperature of 37.5). There were no significant clinical or laboratory differences between the group with subsequent positive tests compared with those who remained negative.

The authors refer to those who have subsequent positive SARS-CoV-2 PCR as having "reactivation" of infection. This is a misnomer as the persistent shedding of viral RNA has been well recognised in adult studies. This includes a large cohort of over 200 patients from Korea with positive tests following negative PCR results, similar to the children in this study. Importantly no onward transmission from these "re-positive" cases was found amongst 790 contacts in the Korean cohort, suggesting the viral RNA detected in patients with prolonged shedding is not viable. Indeed in a recent in vitro study including 90 SARS-CoV-2 PCR positive samples, only samples taken within 8 days of symptoms onset were capable of infecting cells. This is in keeping with contact tracing data suggesting peak transmissibility occurs before and immediately after symptom onset with limited transmission beyond 5 days of symptom onset.

The likely explanation of the "reactivation" described here is prolonged shedding of non-viable viral RNA with an interim "false negative" samples prior to hospital discharge. Given the available data, it is unlikely that these "re-positive" discharged patients represent an infection risk to others

Garcia-Salido, ASerrano-Gonzalez, APediatr Crit Care MedChildren in Critical Care Due to Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Experience in a Spanish Hospital27 May 2020SpainEurope7Clinical - Clinical Featureshttps://journals.lww.com/pccmjournal/Abstract/9000/Children_in_Critical_Care_Due_to_Severe_Acute.98028.aspx
Kumar, KJayanthi, CRIJOPresence of viral RNA of SARS-CoV-2 in conjunctival swab specimens of COVID-19 patients25 May 2020IndiaAsia4Clinical - Clinical Featureshttp://www.ijo.in/temp/IndianJOphthalmol6861015-4225372_114413.pdf
Gefen, AMSethna, CPediatric NephrologyPediatric COVID-19-associated rhabdomyolysis: a case report23 May 2020USANorth America1Clinical - Clinical Featureshttps://link.springer.com/article/10.1007/s00467-020-04617-0
Torrelo AColmenero IPaediatric DermatologyErythema multiforme-like lesions in children and COVID-1923 May 2020ItalyEurope4Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/abs/10.1111/pde.14246
Armann, J.Berner, R.Dtsch Arztebl IntHospital Admission in Children and Adolescents With COVID-1922 May 2020GermanyEurope128Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7271745/
Docherty, ASemple, MBMJFeatures of 20133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study22 May 2020United KingdomEurope310Clinical - Clinical Featureshttps://www.bmj.com/content/bmj/369/bmj.m1985.full.pdf
de Ceano-Vivas, MCalvo CArch Dis ChildSARS-CoV-2 infection in ambulatory and hospitalised Spanish children22 May 2020SpainEurope58Clinical - Clinical Featureshttps://adc.bmj.com/content/archdischild/early/2020/05/22/archdischild-2020-319366.full.pdf

Study design: A retrospective case series of all children seen at a tertiary centre, who were found to have positive PCR for SARS-CoV-2. Testing for SARS-CoV-2 was only conducted in those children who had respiratory symptoms and “criteria for hospitalisation” or who had “underlying chronic pathology”. Children with mild symptoms were not tested even if there was a confirmed case in the household. Comparisons were made between the characteristics of those admitted to hospital and those treated as outpatients. The study was conducted between March 11th and April 9th 2020 at Hospital La Paz, Madrid, Spain.

Inclusion criteria: All children who underwent PCR for SARS-CoV-2 in nasopharyngeal smear, N=349. Of whom 58 (16.6%) had a positive PCR and were the cases analysed.

Key findings: Of the 58 cases: Male 37 (63.8%), Median age 35.5 months (range 3.3-146), Underlying conditions 23 (39.7%), Temperature >39.7degC 41 (70.7%), Cough 42 (72.4%), Rhinorrhoea 33 (56.9%), Breathing difficulty 10 (17.2%), Vomiting 9 (15.5%), Headache 8 (13.8%), Loss of taste 1 (1.7%), Anosmia 1 (1.7%).

Radiology: 40 (69%) had a CXR of which 35 (87.5%) were abnormal: Perihilar infiltrates, ground glass pattern, lobar or multilobar consolidation.

Bloods: 43 (74.1%) had a blood test, median WCC 9145/mm3, median lymphocyte count 2390/mm3.Outcomes: 33 were hospitalised and 25 were treated as outpatients. Of the inpatients, 14 (42.4%) received oxygen therapy for a median of 3 days. 5 were admitted to the PICU (15% of those hospitalised): 3 with severe COVID-19, 1 with a hypertensive crisis and 1 with diabetic ketoacidosis. 31 (53.4%) were treated with hydroxychloroquine, 3 patients were treated with remdesivir. 2 patients with an inflammatory syndrome were also treated with tocilizumab. There was 1 death of a 5/12 old infant with dilated cardiomyopathy and Hurler’s syndrome. The comparisons between the inpatient and outpatient group provide almost no additional useful information.

Comment: As the authors concede, the retrospective nature of the study is a significant weakness. Patients were selected for testing on the basis of symptoms and/or underlying conditions and many other children who could have been infected were never tested. The study is useful in describing the range of symptoms, treatment and outcome in the large selected group of children who tested positive for SARS-CoV-2. It does not, however, add anything new to what is already known about the condition in children.

Scheier, EBalla, UEur Rev Med Pharmacol Sci Lung ultrasound cannot be used to screen for Covid-19 in children21 May 2020IsraelMiddle East1Clinical - Clinical FeaturesCOVID-19 Associated Pediatric Multi-System Inflammatory Syndrome
Li, BYu, CIndian PediatricsRadiographic and Clinical Features of Children With Coronavirus Disease (COVID-19) Pneumonia21 May 2020ChinaAsia22Clinical - Clinical Featureshttps://link.springer.com/content/pdf/10.1007/s13312-020-1816-8.pdf
Leung, CLeung, CPediatric PulmonologyClinical characteristics of COVID‐19 in children: Are they similar to those of SARS?21 May 2020China Asia43Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/10.1002/ppul.24855
Zachariah, PGreen, DClin Infect DisSymptomatic Infants have Higher Nasopharyngeal SARS-CoV-2 Viral Loads but Less Severe Disease than Older Children20 May 2020USANorth America57Clinical - Clinical Featureshttps://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa608/5841161

This research letter details the viral loads of children with confirmed SARS-CoV-2 infection from Columbia University Irving Medical Centre in New York. All children admitted and discharged between March 14th to April 24th 2020 were included, timing of test relative to onset of symptoms, clinical severity along with viral load were compared between infants <1yo and children >1yo.Of 57 patients with positive SARSCoV-2 PCR, 20 (35%) were under 1yo. Compared with older children, viral load was higher amongst infants <1yo (mean cycle threshold 21.05 vs 27.25, p<0.01 - where lower cycle threshold=greater viral load). Infants were tested earlier on average (2 vs 3.8 days from symptom onset) and fewer had severe disease compared with older children (5% vs 32.4%).

In this small hospital-based study symptomatic infants appear were found to have higher viral loads and milder disease compared with older children. This is in contrast to data from some adult studies where a higher viral load correlated with more severe illness.

Amongst several possible explanations for this observation are that: - infants were more likely to be tested early in illness when viral load peaks - declining thereafter - thresholds for hospital presentation may differ between infants and older children - test performance and sample quality may differ between infants and older children - there may possibly be differences in host biology according to age

Although some data suggest that higher SARS-CoV-2 viral load is associated with the presence of viable virus / in vitro infectivity, the exact implications of the findings here in terms of risk of transmission from infants compared with older children is unclear. Further studies examining SARS-CoV-2 viral load dynamics and correlation with clinical course in children are required to better understand potential variation between different age groups.

Venturini, EGalli, LJ PaediatrSevere neutropenia in infants with severe acute respiratory syndrome caused by the novel coronavirus 2019 infection 19 May 2020ItalyEurope2Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236669

This case report from the Meyer Children University Hospital, Florence, published as a letter describes two infants with SARS-CoV-2 with transient severe neutropenia (<0.5 x109/l) Clinical Features: The two female infants, aged 23 days and 39 days were admitted with mild respiratory symptoms and low grade fever. Nasopharyngeal swans were positive for Covid-19. There was no clinical deterioration in their condition during admission.

Radiology: not described

Treatment: not described.

Haematology: leukocytes and neutrophils normal on admission. At 5 days neutrophil counts fell to 0.244 x 109/lnand 0.482 x 109/l. Subsequently both improved.

Apart from age and gender there is no other demographic information nor any on treatments.Although neutropenia is described in 6% of cases of Covid-19, severe neutropenia has not been described. In the report cases it was not associated with any change in clinical state. The authors suggest consideration of performing FBCs 5 to 7 days into the illness to identify neutropenia.It requires further studies to see if these findings are replicated and whether they are clinically significant. The severity of the neutropenia could be age dependent reflecting bone marrow maturity as one patient was in the neonatal range and the other just beyond it.

Xiong XTam, PGutComparative study of the clinical characteristics and epidemiological trend of 244 COVID-19 infected children with or without GI symptoms19 May 2020china Asia244Clinical - Clinical Featureshttps://gut.bmj.com/content/early/2020/05/19/gutjnl-2020-321486.info
Dallan, CSahyoun, CLancetSeptic shock presentation in adolescents with COVID -1919 May 2020SwitzerlandEurope3Clinical - Clinical Featureshttps://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30164-4/fulltext
Venturini, EGalli, LJ PaediatrSevere neutropenia in infants with severe acute respiratory syndrome caused by the novel coronavirus 2019 infection 19 May 2020ItalyEurope2Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236669
Giacomet, VZuccotti, GPIDJAcute inflammation and elevated cardiac markers in a two-month-old infant with severe acute respiratory syndrome coronavirus 2 infection presenting with cardiac symptoms 19 May 2020ItalyEurope1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/ACUTE_INFLAMMATION_AND_ELEVATED_CARDIAC_MARKERS_IN.96157.aspx
Dugue, RMishra, NNeurologyNeurologic manifestations in an infant with COVID-1919 May 2020USANorth America1Clinical - Clinical Featureshttps://n.neurology.org/content/neurology/early/2020/05/18/WNL.0000000000009653.full.pdf
Shaw, RYuki, KJ Pediatr Surg Case Rep.Intubation precautions in a pediatric patient with severe COVID-1918 May 2020USANorth America1Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S2213576620301299
Guarneri, CNunnari, GThe Lancet, Infection diseasesSilent COVID-19: what your skin can reveal18 May 2020Italy (assumed) Europe3Clinical - Clinical Featureshttps://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30402-3/fulltext#coronavirus-linkback-header
Yoo, SKim, D Pediatrics InternationalReactivation of SARS-CoV-2 after Recovery18 May 2020KoreaAsia1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/ped.14312
Li, YWu, BBMC PediatricsChest CT imaging characteristics of COVID-19 pneumonia in preschool children: a retrospective study18 May 2020ChinaAsia8Clinical - Clinical Featureshttps://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-020-02140-7
Turbin, RNimchimsky, EOrbitOrbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID-1918 May 2020USANorth America2Clinical - Clinical Featureshttps://www.tandfonline.com/doi/full/10.1080/01676830.2020.1768560
Wang, Y.Li, L.The Journal of Infectious DiseasesClinical Outcomes in 55 Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Who Were Asymptomatic at Hospital Admission in Shenzhen, China17 May 2020ChinaAsia15Clinical - Clinical Featureshttps://academic.oup.com/jid/article/221/11/1770/5807958
Voinsky, IGurwitz,DJ Infect.COVID-19 Associated Pediatric Multi-System Inflammatory Syndrome. J Paediatric Infect Dis Soc16 May 2020IsraelMiddle East933Clinical - Clinical Featureshttps://www.journalofinfection.com/article/S0163-4453(20)30303-0/fulltext

In this case report from Detroit, USA, the authors describe a 6yo girl with confirmed SARS-CoV-2 and PIMS-TS / MIS-C requiring ECMO.

Following initial presentation with fever, sore throat and rash, the patient developed refractory hypotension and incomplete features of Kawasaki disease (conjunctivitis, rash, swollen peripheries). Inflammatory markers were elevated (CRP 450 mg/L, ESR 54mm/hr, ferritin 699.5 ng/mL) as were troponin (114ng/L), D-dimer (4.21 mg/L), and fibrinogen (834 mg/dL). Echocardiography showed decreased LV function and bloods demonstrated acute kidney injury (creatinine 1.09mg/dL). SARS-CoV-2 RT PCR was positive from a nasopharyngeal swab; earlier in the illness a group A streptococcal rapid test was positive (NP swab).

Despite inotropic support, the patient's condition deteriorated requiring VA ECMO. IVIG, aspirin and antibiotics (vancomycin, ceftriaxone and clindamycin) were given with gradual clinical and biochemical improvement. The authors also allude to incomplete KD like illness in two other patients at their centre with COVID-19 - both with less severe presentations and recovery following IVIG.

This case adds to a growing number of reports of PIMS-TS / MIS-C in children, highlighting the potential for rapid deterioration in this rare condition and the possible role of IVIG in cases with features of Kawasaki Disease.

Duramaz, BTurel, ODermatol TherAppearance of Skin Rash in Pediatric Patients with COVID-19: Three Case Presentations15 May 2020TurkeyWestern Asia, Southeastern Europe20Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/full/10.1111/dth.13594
Diotallevi, FOffidani, AJ Med VirolSkin Involvement in SARS-CoV-2 Infection: Case Series15 May 2020ItalyEurope2Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/10.1002/jmv.26012
He, GCai, JIndian PediatricsSerial Computed Tomography Findings in a Child with Coronavirus Disease (COVID-19) Pneumonia15 May 2020ChinaAsia1Clinical - Clinical Featureshttps://link.springer.com/content/pdf/10.1007/s13312-020-1824-8.pdf
Mastrolonardo, MFoti, CDermatologic TherapyThe management of the outbreak of acral skin manifestationsin asymptomatic children during COVID-19 era14 May 2020ItalyEurope38Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/dth.13617
Craver, RFinger, LFetal Pediatr PatholFatal Eosinophilic Myocarditis in a Healthy 17-Year-Old Male with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2c)13 May 2020USANorth America1Clinical - Clinical Featureshttps://www.tandfonline.com/doi/full/10.1080/15513815.2020.1761491
Cordoro, KMMcCalmont, THPediatric DermatologyClustered Cases of Acral Perniosis: Clinical Features, Histopathology and Relationship to COVID‐1912 May 2020USNorth America6Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/abs/10.1111/pde.14227
DeBiasi, RWessel, DJ Pediatr.Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region12 May 2020United StatesNorth America177Clinical - Clinical Featureshttps://www.jpeds.com/article/S0022-3476(20)30581-3/fulltext

This is retrospective cohort study, describing 177 children and young adults with confirmed SARS-CoV-2 infection treated between March 15 and April 30 2020 at Children’s National Hospital, Washington DC US. Children and young adults were detected through symptomatic presentation at emergency departments, ambulatory clinics, inpatient units, or by referral for admission from external facilities. Of 177 patients, 44 (25%) were hospitalised, with 9 (5%) classified as critically ill. The aim of the study was to identify if any specific epidemiological or clinical features associated with hospitalisation, or critical care.

Of note this hospital served as a regional centre for providing critical care for young adults aged 21 – 35 years, therefore not all patients would be termed “paediatric patients”. Overall patient age range was from 0.1 - 34.2 years, with a median of 9.6years. Of the total group 12/177 were > 20 years of age, and 37/177 were between age of 15 – 20years.

Results: Age; There was no significant difference in age between the hospitalised and non-hospitalised patients, however in the hospitalised cohort, the critically unwell group were significantly older than the non-critically unwell hospitalised group (17.3 years versus 3.6 years; P =.04) Sex; There was equal representation in total cohort showed (n = 177 52% male, 48% female), as well as the hospitalised cohort (n=44 50% male, 50% female). However males made up 67% of the critically ill cohort (n =9, 67% male, 33% female); but this was not statistically significant (p=0.26)Race/ethnicity: data not provided, authors describe plans to do so in follow up analysis Underlying conditions; 39% of positive patients had an underlying condition (classified as asthma, diabetes, neurological, obesity, cardiac, haematological, oncological). Though asthma was the most common underlying condition (35/177 20%), it was not more common in hospitalised patients (7/44 16%), nor of those admitted, those who were critically unwell (2/9, 22%). Though the numbers where small, specific underlying conditions such as neurological, cardiac, haematological, or oncological underlying conditions were more common in the hospitalised cohort than the non hospitalised cohort. But were not more common in the hospitalised critically ill compared with the hospitalised non critically ill. The authors noted there was no underlying condition present in 96/177 (55%) of overall SARS-CoV-2 infected patients overall, 16/44 (37%) of hospitalized patients and in 2/9 (22%) of critically ill patients.Symptoms; 76% of infected patients presented with respiratory symptoms (rhinorrhea, congestion, sore throat, cough or shortness of breath) with or without fever. Fever was present in 116/177 (66%) but was not more common in the infected hospitalized cohort (34/44, 77%) compared with the non-hospitalized cohort (82/133, 62%; p=0.46). 

Shortness of breath was more common in the hospitalized cohort (11/44, 26%) compared with non-hospitalized (16/133, 12%; p=0.04). Patients in the critically ill cohort were not more likely to have fever or any other specific symptom compared with the non-critically ill cohort.

Critical Care: 9 patients required critical care; which represented 5% (9/177) of total cohort and 20% (9/44) of admitted patients. 4 required intubation (3 ARDS, 2 multiple organ failure); 3 required BiPAP, 1 RAM cannula and 1 High flow nasal cannula. One patient had features consistent with the recently emerged Kawasaki disease-like presentation with hyper-inflammatory state, hypotension and profound myocardial depression; a 4 year male with no underlying conditions.

Summary: A very clear description of 177 patients with Sars CoV 2, in one large centre in Washington DC. 25% of patients needed hospitalisation and 5 % needed critical care. Older teenagers and adults who required admission, were then overrepresented in requiring critical care. Though underlying conditions were more common in hospitalised patients, they were not significantly more common in the hospitalised patients who required critical care. Shortness of breath was the only symptom that was more common in hospitalised patients than non-hospitalised patients. No specific symptom was more apparent in patients needing critical care. One critically ill patient had features of recently described hyperinflammatory state.

Bai, KLi, CPIDJClinical analysis of 25 Novel Coronavirus Infections in Children 12 May 2020China Asia25Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/Clinical_Analysis_of_25_Novel_Coronavirus.96172.aspx
Brambilla, IMarseglia, GLThe Pediatric Infectious Disease JournalCOVID-19 in the Pediatric Population Admitted to a Tertiary Referral Hospitap in Northern Italy: Preliminary Clinical Data12 May 2020ItalyEurope17Clinical - Clinical Featureshttps://journals.lww.com/pidj/Citation/9000/COVID_19_in_the_Pediatric_Population_Admitted_to_a.96177.aspx
Brambilla, I.Ciprandi, G.Obesity: A research journalSpecial Issues for COVID‐19 in Children and Adolescents12 May 2020ItalyEurope1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/abs/10.1002/oby.22878
Meslin, PZemouri, NThe Pediatric Infectious Disease JournalCoronavirus Disease 2019 in Newborns and Very Young Infants a Series of Six Patients in France12 May 2020FranceEurope6Clinical - Clinical Featureshttps://journals.lww.com/pidj/Fulltext/2020/07000/Coronavirus_Disease_2019_in_Newborns_and_Very.33.aspx
Cai, XLi, WFront. PediatrClinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children12 May 2020ChinaAsiaClinical - Clinical Featureshttps://www.frontiersin.org/articles/10.3389/fped.2020.00258/full
Shekerdemian, LSBurns, JPJAMA PediatricsCharacteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units11 May 2020USA & CanadaNorth America48Clinical - Clinical Featureshttps://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037

This is a cross-sectional study of children admitted to 46 PICUs in North America. 48 children were admitted during the collection period (March 14 to April 3 2020). All had confirmed COVID-19 infection on PCR from a nasal swab.

Most patients presented with respiratory symptoms, but there were other presentations – three with DKA, and one with vaso-occlusive crisis (sickle cell). 86% of these patients had at least one comorbidity. 69% were severely or critically ill on admission, and 25% needed vasoactive drugs. 81% of patients needed respiratory support that exceeded their baseline.

61% had a range of therapies, including Hydroxychloroquine, Azithromycin, Remdisivir, and Tocilizumab. These were used as single agents or in combination with other therapies.

The overall mortality rate was 4.2% (both patients who died had pre-existing comorbidities and developed multisystem organ failure). 32% were still hospitalised at the time of publication (including one patient still receiving ECMO). 65% had been discharged.

This study reinforces what is known about the decreased burden of disease from COVID-19 in children compared with adults. Critically ill children had a less severe course of illness and better hospital outcomes than in adults. Children commonly had medically complex comorbidities. Overall the mortality is much lower in children (4.2%) than has been reported in adults (50-62%).

Chao, JMedar, SJ. Pediatr.Clinical Characteristics and Outcomes of Hospitalized and Critically Ill Children and Adolescents with Coronavirus Disease 2019 (COVID-19) at a Tertiary Care Medical Center in New York City 11 May 2020USNorth America46Clinical - Clinical Featureshttps://www.jpeds.com/article/S0022-3476(20)30580-1/pdf
Wehl, G..Rauchenzauner, MKlin PadiatrCo-infection of SARS CoV-2 and influenza A in a Pediatric Patient in Germany.11 May 2020GermanyEurope1Clinical - Clinical Featureshttps://www.thieme-connect.com/products/ejournals/abstract/10.1055/a-1163-7385
Oberweis, MGarcia, IPediatr. Infect. Dis. J.Pediatric Life-Threatening Coronavirus Disease 2019 With Myocarditis11 May 2020LuxembourgEurope1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/Pediatric_Life_Threatening_Coronavirus_Disease.96160.aspx

In this case report from Luxembourg, the authors describe an 8yo boy of African ethinicity with COVID-19 complicated by myocarditis. Presenting features included fever, cough, fatigue and cervical adenopathy associated with painful erythematous swelling of the skin. Following admission, the patient developed renal failure and refractory hypotension necessitating ICU admission. CRP (151mg/L), ferritin (2869ng/mL), D-dimer and IL-6 were all elevated. Echocardiography demonstrated myocarditis with biventricular dysfunction and troponin was elevated. SARS-CoV-2 infection was confirmed on RT-PCR of nasopharyngeal swab and stool; serology (IgA and IgG) was also positive.

IVIG and tocilizumab (anti-IL-6 monoclonal antibody) were given along with supportive care including enoxaparin and inotropes. The patient made a full recovery with resolution of changes on repeat cardiac imaging and was discharged home on day 10.

This case, likely submitted prior to the description of PIMS-TS / MIS-C, fits with the definition for these syndromes. The myocarditis, refractory hypotension, overlap with features of Kawasaki Disease, laboratory findings suggestive of cytokine storm as well as the patient's African ethnicity are all in keeping with recent reports from UK, Europe and the US. The authors postulate that the "cardiac injury could be due to disproportionate host immune response to SARS-CoV2" and describe a rapid clinical response following administration of tocilizumab.

With emerging reports of PIMS-TS / MIS-C, our understanding of the pathophysiology of this condition will increase. At this stage the role of immunomodulatory agents remain uncertain in PIMS-TS / MIS-C; discussion with paediatric ID clinicians on a case by case basis is recommended.

Zhang, NZheng, XTransl PediatrAnalysis and suggestions for the preview and triage screening of children with suspected COVID-19 outside the epidemic area of Hubei Province10 May 2020ChinaAsia36Clinical - Clinical Features http://dx.doi.org/10.21037/tp.2020.03.08
Andina, D.Torello, A.Paediatric DermatologyChilblains in children in the setting of COVID-19 pandemic9 May 2020SpainEurope22Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/pde.14215
Locatelli, ASena, PJ Eur Acad Dermatol VenereolHistologic features of long lasting chilblain‐like lesions in a pediatric COVID‐19 patient9 May 2020ItalyEurope1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/jdv.16617

This retrospective single case report describes clinical and pathological signs of chilblain-like lesions whilst the patient was asymptomatic. He did not have any signs of autoimmune conditions including on histological examination. The lesions persisted for several weeks whilst he remained positive for SARS-CoV-2 on nasopharyngeal swab. The authors highlight young people with this sign could be carriers of the virus.

A 16-year-old male patient attended Papa Giovanni XXIII Hospital, Italy. His nasopharyngeal swab was positive for SARS-CoV-2. His mother was admitted to hospital for SARS-CoV-2 management following his presentation.

Clinical features: Diarrhoea and dysgeusia were experienced 3 days prior to the onset of skin lesions described as “multiple asymptomatic erythematous oedematous partially eroded macules and plaques on dorsal aspects of the fingers”. A lesion was also noted on second toe.

Radiology: None discussed.

Bloods: "Routine bloods autoimmunity, cryoglobulins, viral serologies all negative or within normal limits"

Treatments: None

Outcomes: Was treated on a hospital ward without supplemental oxygen until discharge.

Other features of interest: Histopathological examination demonstrated oedema of the papillary dermis, superficial and deep lymphocytic infiltrate in the perivascular and strong peri-eccrine pattern. Images are provided.

Diercks, GRKwolek, CJInternational Journal of Pediatric OtorhinolaryngologyAsymptomatic COVID-19 infection in a child with nasal foreign body8 May 2020USANorth America1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205643/pdf/main.pdf
Fu, BFu, XMed Clin (Barc)Clinical characteristics of 11 asymptomatic patients with COVID-198 May 2020ChinaAsia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205640/pdf/main.pdf
Ma, Y.Zhang, Z.Microbes and InfectionCharacteristics of asymptomatic patients with SARS-CoV-2 infection in Jinan, China7 May 2020ChinaAsia10Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204664/pdf/main.pdf
Zhang, YSun, BCell Mol ImmunolProtective humoral immunity in SARS-CoV-2 infected pediatric patients7 May 2020China Asia6Clinical - Clinical Featureshttps://www.nature.com/articles/s41423-020-0438-3

This is a study looking at the immune responses of 6 children with Sars-CoV-2 infection and comparing it to controls, in hospitals in China, in “areas other than Wuhan”. The clinical characteristics of the children were described previously (Cai et al Clin. Infect. Dis. 2020). All six children had positive respiratory samples RT PCR positive for Sars-Cov-2. All had a mild respiratory illness, needing no supportive treatment.

It is somewhat difficult to interpret exactly what immunological tests were done on which child from the study report. However, flow cytometry analysis analysing T and B cells was performed on 4 of the positive patients and was compared to five uninfected controls, admitted to the same hospital for non Sars-CoV-2 related reasons. There was no significant difference in lymphocyte count, or percentage of CD3+, CD4+, and CD8+ T cells between positive or control groups. The percentage of IgG+ in total B cells was higher, though not significantly, between groups but the percentage of IgG+ memory B cells was significantly higher in infected group.

The authors used Nucleocapsid protein and receptor binding domain of spike protein (spike-RBD) of SARS-COV-2 as antigen. All 6 infected children were tested for antigen specific antibodies, with 5 of 6 children producing antigen specific antibodies between 2 – 17 days post infection (it is unclear whether these were serial samples, or opportunistic sampling, therefore exact time of production of antigen specific antibodies is unclear). The team report that most of the IgM antibody for spike RBD Sars-CoV-2 was undetectable shortly after disease onset, suggesting class switching occurred within one week of virus exposure.

The team went on to select select serum from one patient with high concentration of spike RBD protein, and demonstrated in vitro it could block the receptor binding between spikeprotein and ACE2 protein, which is considered a vital pathway for Sars-CoV-2 to infect.

Authors conclude that the efficient humoral immune response might explain why the majority of children infected with SARS-CoV-2 had milder symptoms and recovered more easily than adults.

Papa, AVarrassi, GPain TherImages in Practice: Painful Cutaneous Vasculitis in a SARS-Cov-2 IgG-Positive Child6 May 2020ItalyEurope1Clinical - Clinical Featureshttps://link.springer.com/content/pdf/10.1007/s40122-020-00174-4.pdf
Ma, H.Shao, J.BMC MedicineA single-center, retrospective study of COVID-19 features in children: a descriptive investigation6 May 2020ChinaAsia158Clinical - Clinical Featureshttps://bmcmedicine.biomedcentral.com/track/pdf/10.1186/s12916-020-01596-9
Zhang, BZhang SJ InfectionChildren hospitalized for coronavirus disease 2019 (COVID-19): A multicenter retrospective descriptive study6 May 2020ChinaAsia46Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204760/pdf/main.pdf
Wang, YSun, DPediatr Infect Dis JThe Risk of Children Hospitalized With Severe COVID-19 in Wuhan6 May 2020ChinaAsia43Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/research/coronavirus/publication/32384397
Colonna, C. Gelmetti, C.Paediatric DermatologyChilblains-like lesions in children following suspected Covid-19 infection6 May 2020ItalyEurope4Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/pde.14210
Li, J.Song, S.Q.The Brazilian Journal of INFECTIOUS DISEASEAn infant with a mild SARS-CoV-2 infection detected only by anal swabs: a case report6 May 2020ChinaAsia1Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S141386702030043X
Xiong, X.Tam, P.Med archivesAre COVID-19 infected children with gastrointestinal symptoms different from those without symptoms? A comparative study of the clinical characteristics and epidemiological trend of 244 pediatric cases from Wuhan5 May 2020ChinaAsia244Clinical - Clinical Featureshttps://www.medrxiv.org/content/10.1101/2020.04.29.20084244v1
Lu, YDu, HPed Infectious Disease JSymptomatic Infection is Associated with Prolonged Duration of Viral Shedding in Mild Coronavirus Disease 2019: A Retrospective Study of 110 Children in Wuhan5 May 2020ChinaAsia110Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/Symptomatic_Infection_is_Associated_with_Prolonged.96181.aspx

This retrospective study analysed demographic, clinical, laboratory, radiological and therapeutic data from the electronic medical records of 110 children hospitalised with “mild/ordinary” COVID-19 (classified as per the National Health Commission of People’s Republic of China National Recommendations for Diagnosis and Treatment of COVID-19, 7th edition) at Wuhan Children’s Hospital in Hubei, China between 30th January and 10th March 2020. Inclusion criteria: throat or nasopharyngeal swabs RT-PCR SARS-CoV-2 positive and patient discharged from hospital after recovery (an initial cohort of 127 children was reduced to 110 after exclusion of 2 critical cases and 15 children in whom the onset of disease could not be accurately determined).

Study design: Timings of onset of illness, most recent exposure (presumably to SARS-CoV-2-confirmed or symptomatic contacts, although this isn’t specified), diagnosis and discharge from hospital were recorded. Patients were discharged only once they had two consecutive RT-PCR SARS-CoV-2 negative swab results (separated by at least 24 hours). The authors calculated the duration of viral shedding for (a) symptomatic patients (81/110, 74%) as time from onset of illness to discharge and for (b) asymptomatic patients (29/110, 26%) as time from date of most recent exposure OR abnormal chest radiological imaging (reason for imaging not specified in these asymptomatic patients) to discharge. This definition of duration of viral shedding, with starting point presumably in most cases a retrospective parent-reported start of symptoms or exposure to an infectious contact, and end point two negative swabs leading to discharge from hospital, makes interpreting the duration figures problematic. Viral shedding in urine and faeces was not measured.

Clinical features: Median age of the 110 children was 6 years (IQR 2-9); 59/110 male (54%), 51/110 female (46%). Symptoms included: cough and dyspnoea 57/110 (52%), fever 56/110 (51%), GI (including diarrhoea, vomiting, poor feeding, anorexia, abdominal pain) 26/110 (24%), rhinorrhoea 10/110 (9%).Radiology: 64/103 (62%) had unspecified chest imaging reported as demonstrating pneumonia (55/75 symptomatic (73%) and 9/28 asymptomatic (32%)).

Bloods: Leucocytes < 4.0 x 109/L in 6/110 (5%) (all 6 were symptomatic). Leucocytes > 10.5 x 109/L in 12/110 (11%) (9 symptomatic & 3 asymptomatic). Lymphocyte ranges not specified. Haemoglobin < 110 g/L in 13/110 (12%) (all 13 symptomatic). Fibrinogen < 2.0 g/L in 34/90 (38%) (20 symptomatic & 14 asymptomatic). Hs-CRP > 3.0 mg/L in 21/110 (19%) (18 symptomatic & 3 asymptomatic). Procalcitonin > 0.05 ng/mL in 52/110 (47%) (43 symptomatic & 9 asymptomatic). AST > 50.0 U/L in 19/110 (17%) (all 19 symptomatic).

Treatment: None of the patients required oxygen therapy. All of them received antiviral therapy, mostly commonly nebulised interferon-. According to the data table 22/110 received Chinese medicine therapy, although no details are given and it’s not clear if this was pre-hospitalisation. Median duration of hospital stay was 10 days (IQR 8-13).

Conclusions: The median duration of viral shedding using the definitions above was 15 days overall (IQR 11-20 days, range 5-37 days): 17 days (IQR 12-23) in symptomatic patients and 11 days (IQR 9-13) in asymptomatic patients. Symptomatic infection, fever, pneumonia and lymphocyte counts < 2.0 x 109/L were reported to be associated with prolonged duration of shedding.

Garcia-Lara, G.Ruiz-Villaverde, R.Dermatologic TherapyChilblain-like lesions in pediatrics dermatological outpatients during the COVID-19 outbreak 5 May 2020SpainEurope27Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/dth.13516
Merza, MAbdulah, D.Diabetes Metab SyndrCOVID-19 outbreak in Iraqi Kurdistan: The first report characterizing epidemiological, clinical, laboratory, and radiological findings of the disease5 May 2020Iraqi KurdistanMiddle East4Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199697/
Hong-Rui, C.Wan-Xin, C.The Pediatric Infectious Disease Journal:A CASE OF CHILDHOOD COVID-19 INFECTION WITH PLEURAL EFFUSION COMPLICATED BY POSSIBLE SECONDARY MYCOPLASMA PNEUMONIAE INFECTION5 May 2020ChinaAsia1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/A_CASE_OF_CHILDHOOD_COVID_19_INFECTION_WITH.96183.aspx
Peng, HXu, HJ Clin VirologyCoronavirus disease 2019 in children: Characteristics, antimicrobial treatment, and outcomes4 May 2020China Asia75Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204737/table/tbl0010/
Rahmanzade, RHashemian, SA A PractRespiratory Distress in Postanesthesia Care Unit: First Presentation of Coronavirus Disease 2019 in a 17-Year-Old Girl: A Case Report4 May 2020IranAsia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227797/pdf/acc-14-e01227.pdf
Morey-Olive, MGarcia-Patos, VAnales de pediatriaCutaneous manifestations in the current pandemic of coronavirus infection disease (COVID 2019)4 May 2020SpainEurope2Clinical - Clinical Featureshttps://www.analesdepediatria.org/en-cutaneous-manifestations-in-current-pandemic-avance-S2341287920300673
Nirenberg, M.Herrera, MDMRJ Am Podiatr Med Assoc.Foot Manifestations in a COVID-19 Positive Patient, A case study4 May 2020SpainEuropeClinical - Clinical Featureshttps://www.japmaonline.org/doi/pdf/10.7547/20-088
Zheng, ZLiu, JJ Cent South Univ (Med Sci)Chest CT findings and clinical features of coronavirus disease 2019 in children3 May 2020ChinaAsia9Clinical - Clinical Featureshttp://xbyxb.csu.edu.cn/xbwk/fileup/PDF/202003236.pdf
Sun, JWang, YJ Infect Dev CtriesDifferent outcome of COVID-19 in members of a family3 May 2020ChinaAsia1Clinical - Clinical Featureshttps://jidc.org/index.php/journal/article/download/12792/2248
Steinberger, SLittle, B PAm J RoentgenolCT Features of Coronavirus Disease (COVID-19) in 30 Pediatric Patients 1 May 2020ChinaAsia30Clinical - Clinical Featureshttps://www.ajronline.org/doi/10.2214/AJR.20.23145
Qiu, LLuo, XPediatr Infect DisA Typical Case of Critically Ill Infant of Coronavirus Disease 2019 With Persistent Reduction of T Lymphocytes1 May 2020ChinaAsia1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/9000/A_Typical_Case_of_Critically_Ill_Infant_of.96189.aspx
Tsao, HSFearon, DMPediatricsThrombocytopenia (ITP) in a SARS-CoV-2 Positive Pediatric Patient1 May 2020USANorth America1Clinical - Clinical Featureshttps://pediatrics.aappublications.org/content/pediatrics/early/2020/05/19/peds.2020-1419.full.pdf
Zhu, XCiu, LVirusResCo-infection with respiratory pathogens among COVID-2019 cases30 Apr 2020China Asia11Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S0168170220303531
Yu, X.Fu, C.Transboundary and Emerging diseasesEpidemiological and clinical characteristics of 333 confirmed cases with coronavirus disease 2019 in Shanghai, China29 Apr 2020ChinaAsia10Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/10.1111/tbed.13604
Casas, CGarcia-Doval, IBr J DermatologyClassification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases29 Apr 2020spainEurope0Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/bjd.19163

This article from a team in Spain aimed to classify cutaneous manifestations of COVID-19 and relate them to other clinical findings.

From 3rd of April 2020 to 16th of April 2020 they collected 429 cases but excluded 54 leaving a sample of 375 patients. A standardised questionnaire was used, photographs were taken and the questionnaires and photographs were independently reviewed by 4 dermatologists.

Data was collected by Spanish dermatologists from across the country most of whom had been redeployed from their usual dermatology posts.

Patients with an eruption of recent onset (previous 2 weeks) and no clear explanation, plus suspected or confirmed COVID-19 were included.They describe 5 cutaneous manifestations.

Acral areas of Erythema-oedema with some vesicles or pustules: 19% of cases. These were more likely in children.

Other vesicular eruptions: 9%. May also affect the limbs and have a haemorrhagic content, and become larger or diffuse.

3 Urticarial lesions: 19%. Mostly distributed in the trunk or disperse. A few cases were palmar.

Other maculopapular: 47%. Some showed perifollicular distribution and varying degrees of scaling, Some had been described as similar to pityriasis rosea.Livedo or necrosis: 6% Strengths of this study are the large number of patients recruited and that four dermatologists independently reviewed the images. It adds to the understanding of skin manifestations of COVID-19, which may give additional information when trying to make a clinical diagnosis of COVID-19 if other symptoms are non-specific, also the cutaneous manifestations may persist for some time once other symptoms have resolved.

A weakness is the authors did not specify the age of the patients involved so the usefulness for paediatric patients is limited. Also, in some areas, diagnosis of COVID-19 infection could only be made clinically, based on symptoms as the ability to test patients was limited during the height of the pandemic.

Chacon-Aguilar, R.Perez-Moneo, B.An Padiatric (Engl Ed)COVID-19: Fever syndrome and neurological symptoms in a neonate27 Apr 2020SpainEurope1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183976/
Nathan, NCorvol, HLancetAtypical presentation of COVID-19 in young infants27 Apr 2020FranceEurope5Clinical - Clinical Featureshttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30980-6/fulltext

This correspondence in the Lancet describes the clinical features of 5 infants with COVID-19 who were admitted to a Paris hospital during the first week after imposed population quarantine in France (from 17th March 2020). At this time at Trousseau Hospital, children needing admission with fever or respiratory symptoms (or both) were admitted to a dedicated SARS-CoV-2 infection unit: during this week 14 infants under the age of 3 months were admitted and of these 5 out of 14 were confirmed SARS-CoV-2 positive on nasopharyngeal swabs.

Age/gender of infants: All 5 of these previously healthy infants with COVID-19 were boys; ages ranged from 1.6 to 2.7 months (median 2.1). All of their parents had mild signs of viral infection (including fever, cough, rhinitis), which could have been indicative of undiagnosed COVID-19.Clinical features at presentation: 5/5 fever (range 37.4 to 38.5 C), 4/5 neurological signs (drowsiness/hypotonia/abnormal “moaning” cry), 4/5 mottled skin, 4/5 runny nose, 4/5 cough, 0/5 dyspnoea, 5/5 normal SpO2, 0/5 digestive symptoms.

Investigations: FBC, CRP & procalcitonin largely unremarkable, with the exception of lymphopaenia in 2/5. Lumbar punctures in 4/5 babies with abnormal neurology reported normal (including negative for RT-PCR SARS-CoV-2). Chest X-rays performed in 4/5 essentially normal.

Outcomes: All 5 showed rapid clinical improvement and received no drugs other than paracetamol. Inpatient stays ranged from 1 to 3 days and duration of fever ranged from 1 to 5 days (max 39C). The infants were followed up for 2 weeks post-discharge with a daily phone call from a paediatrician using a standardised questionnaire.

Conclusion: This encouraging report of a small cohort of SARS-CoV-2 positive infants under the age of 3 months presenting Atypical presentation of COVID-19 in young infantswith fever showed initially concerning signs on admisson, but rapid recovery and minimal intervention needed for all 5 infants.

Piccolo, VBassi, AJournal of the European Academy of Dermatology and VenereologyChillblain-like lesions during COVID-19 pandemic: a preliminary study on 63 patients24 Apr 2020ItalyEurope63Clinical - Clinical Featureshttps://doi.org/10.1111/jdv.16526

This is a report of chilblain like lesions observed during the COVID-19 pandemic, collected through a survey issued to Italian dermatologists and Paediatricians. This is a preliminary report as data collection still ongoing.

Importantly – very few patients in this cohort were tested for COVID-19 (11/63) and only 2 of these patients were positive. It is therefore difficult to extrapolate these findings to paediatric COVID-19 specifically, but is worth being aware of.

63 patients have been reported on with a median age of 14 years (IQR 12 – 16yrs) with feet alone being bar far the most commonly affected area (85/7%) followed by feet and hands together (7%). In uploaded pictures from 54 patients, erythematous-oedematous lesions were most common (31/54) followed by blistering lesions (23/54) and pain and itch were common, although a quarter of lesions were “asymptomatic”. Median time of onset of rash to diagnosis was 10 days. The lesions were generally stable and no other cutaneous signs observed. GI symptoms were the most common co-existing (11.1%) with surprisingly low levels of respiratory symptoms (7.9%).

This is basically a description of a common skin manifestation which coincided with COVID-19, and looked like it could be infectious in origin. Few patients tested, and even fewer positive. An interesting series worth bearing in mind given increasing reports of skin manifestation of COVID-19.

Racalcati, SFantini, FJ Eur Acad Dermatol VenereolAcral cutaneous lesions in the time of COVID-1924 Apr 2020ItalyEurope11Clinical - Clinical Featureshttps://doi.org/10.1111/JDV.16533

This pre-print Letter to the Editor reports on a series of unusual dermatological manifestations presenting to the Dermatologic Unit in Alessandro Manzoni Hospital, Italy in March and April 2020. The authors observed 14 cases, of which 11 were children with a mean age of 14.4 years and a range of 13-18 years. Of the 14 cases, 6 (43%) were male. 3 pairs of cases were siblings.

None of the cases had systemic symptoms (other than mild itch in 3 cases), there was no association with cold exposure, co-morbidities or drug intake, and there was no family history of COVID-19 related symptoms. 3 cases reported cough and fever 3 weeks prior to the onset of the lesions.

The authors believe that these dermatological findings are related to COVID-19 due to the rapid outbreak and clustering of these unusual skin lesions occurring at the same time as the COVID-19 outbreak. In support of this they report multiple similar cases being described from other areas affected by the pandemic. They hypothesise that the skin lesions may represent late manifestations of COVID-19 infection in young, healthy subjects, possibly due to an immunologic response targeting the cutaneous vessels. They accept that this hypothesis cannot be tested until a reliable serological test for antibody response to COVID-19 has been developed.

Clinical features: Acral eruption of erythemato-violaceous papules and macules, with possible bullous evolution or digital swelling. Lesions were found on the feet in 8 cases, hands in 4 cases, and on both sites in 2 cases. 2 children developed erythemato-papular targetoid lesions on the hands and elbows after a few days.

Histology: Lesions on fingers showed diffuse dense lymphoid infiltrate of the superficial and deep dermis, with a prevalent perivascular pattern and signs of endothelial activation. Targetoid lesions on elbows showed mild superficial perivascular dermatitis.

Bloods: Normal FBC, CRP, LDH and D-dimer. Serology was negative for EBV, CMV, Coxsackie and Parvovirus B19.

Outcomes: In all cases the lesions resolved without treatment after 2-4 weeks. It is worth noting that this study is limited both by the small number of cases, but more particularly by the lack of evidence linking these skin lesions with a proven COVID-19 infection.Piccolo et al (Clinical)

Landa, NAguirre, TInternational Journal of DermatologyChillblain-like lesions on feet and hands during the COVID-19 pandemic24 Apr 2020SpainEurope2Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/ijd.14937
Wu, PNie, SGraefes Arch Clin Exp OphthalmolA child confirmed COVID-19 with only symptoms of conjunctivitis and eyelid dermatitis24 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://link.springer.com/article/10.1007/s00417-020-04708-6
Zhang, BZhang SJ InfectPositive rectal swabs in young patients recovered from coronavirus disease 2019 (COVID-19)23 Apr 2020ChinaAsia3Clinical - Clinical Featureshttps://www.journalofinfection.com/article/S0163-4453(20)30233-4/fulltext

In this case series from Dongguan, China, three normally fit & well children aged 14y, 13y and 10m were followed up after positive throat swab for SARS-CoV-2. All three had a subsequent negative throat swab within approximately 7 days, and fully recovered, however 7-9 days later all three had rectal swabs which were positive. These findings raise the question of whether apparently well COVID-19 patients continue to carry and possibly shed the virus. If this was found to be the case in larger and more comprehensive studies, there may be an argument for introduction of strategies to increase avoidance of transmission via the faecal-oral route.

Huang, LZhou, JClin ImagInitial CT imaging characters of an imported family cluster of COVID-1923 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175903/#!po=31.2500
Kan, MJGreenhow, TLJ Ped Inf Dis SocFever without a source in a young infant due to SARS-CoV-222 Apr 2020United States North America1Clinical - Clinical Featureshttps://doi.org/10.1093/jpids/piaa044
Carrabba, GLocatelli, MLancetNeurosurgery in an infant with COVID-1922 Apr 2020Italy Europe1Clinical - Clinical Featureshttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30927-2/fulltext
Kan, M. JGreenhow, T. LJ Pediatric Infect Dis Soc.Fever without a source in a young infant due to SARS-CoV-222 Apr 2020USANorth America1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188112/
Genovese, GMarzano, AVPediatr DermatolVaricella-like exanthem associated with COVID-19 in an 8-year-old girl: A diagnostic clue?21 Apr 2020ItalyEurope1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/pde.14201

This single case report describes an 8 year old girl presenting on a hospital in Milan, Lombardy region, Italy, on 21 March 2020 with a painless, non-pruritic papulovesicular rash on the trunk developing 3 days after onset of a mild cough. The rash was predominantly papular with some vesicles with crusting, similar in appearance to chickenpox. Limbs, face, genitalia and mucous membranes were spared. She developed a mild fever 5 days after the onset of the rash, and tested positive for SARS-CoV-2. She had bloods including FBC, renal function, liver function and CRP, all of which were normal with the exception of a mild thrombocytopenia with platelets of 105 x 109/L, which subsequently normalised. The rash lasted 7 days, by which time systemic symptoms had resolved. The young girl had a history of varicella infection a year previously.

The authors quote other case reports of cutaneous manifestations associated with COVID-19: petechial rash, widespread urticaria and varicella-like rash predominantly involving the trunk. Although unable to confirm that the rash was definitely associated with COVID-19, they feel it is likely given the child’s previous history of varicella infection and lack of pruritis to suggest the lesions were insect bites. They suggest papulovesicular eruptions be included in the spectrum of exanthems possibly associated with COVID-19.

Li, HXu, QJ Infect The Profile of Peripheral Blood Lymphocyte Subsets and Serum Cytokines in Children With 2019 Novel Coronavirus Pneumonia20 Apr 2020China Asia40Clinical - Clinical Featureshttps://www.sciencedirect.com/science/article/pii/S0163445320302073?via%3Dihub

This was a retrospective observational study, studying lymphocyte subsets and serum cytokines of 40 children admitted with 2019-nCoV pneumonia to Wuhan Children’s Hospital between 24 January and 22 February 2020. These were compared against the lymphocyte subsets and serum cytokines of 16 children admitted with RSV pneumonia to the same hospital between 10 December 2019 and 22 February 2020. Study authors report they could not compare 2019-nCoV pneumonia to healthy controls, as the city was in lockdown.

It is not described how these patients were selected from all patients admitted with 2019-nCoV pneumonia, and RSV pneumonia, and what proportion the included patients were of the total admitted patients with these conditions.

There were 40 children with 2019-nCoV pneumonia, diagnosed by real time PCR. The mean age was 5.07 years (4.71 SD). 23 were male, with 17 females. All 40 children had a CT performed, 16 had unilateral changes, 26 had bilateral changes, and 1 had no changes. Severity was classed as needing ICU admission, only 1 out of 40 was classed as “severe”.

There were 16 children with RSV pneumonia included with mean age of 1.36 years (0.85 SD). 10 were male, 6 were female. All had CT chest, with 3 unilateral changes, 12 bilateral changes, and 1 with no changes. 2 out of 16 required were classified as severe and needed ICU admission.

Lymphocyte subsets were drawn within first 3 days of admission. Those treated with glucocorticoids (3 2019-nCoV and 4 with RSV pneumonia) had them taken before steroids were administered. They compared mean and % between patient groups. Mean CD3+ CD8+ are higher in 2019-nCoV patients; mean 933N/µL(SD 421) than RSV patients mean 675 N/µL (SD 426) (p = 0.044), CD3+ CD8+ % were also significantly higher in 2019-nCoV pneumonia patients. IL10 levels were significantly lower in children with 2019-nCoV pneumonia, though exact figures were not given. The child with severe 2019-nCoV had serial lymphocyte subsets. The authors concluded that immune responses could play a significant role in the disease and influence the severity of response.

The limitations of the study discussed were the small numbers, the very few patients with severe illness and the lack of a normal control. The authors did not comment on the significant age differences between the groups, and how these patients were selected.

Richardson, SDavidson, KJAMA networkPresenting Characteristics, Comorbidities and Outcomes among 5700 patients hospitalized with COVID-19 in the New York City area20 Apr 2020USANorth America34Clinical - Clinical Featureshttps://jamanetwork.com/journals/jama/fullarticle/2765184

This is a paper from New York, USA, looking at the presenting characteristics, comorbidities, and outcomes of 5700 patients who were hospitalized with Covid-19. These were patients who were admitted to one of 12 Northwell Health acute care hospitals between 01/03/2020 and 04/04/2020. Clinical outcomes were monitored until 04/04/2020. All patients who were sufficiently medically ill to require hospital admission with confirmed severe acute respiratory syndrome coronavirus 2 infection by positive result on PCR testing of an NPA were included. The median age of patients was 63 years (IQR 52-75), 39.7% were female.

At presentations, 30.7% of patients had a temperature of over 380C. 20% had oxygen saturations of less than 90%. 43.1% of patients were considered tachycardic with a heart rate of over 100.

The majority of patients white cell count and differentials were within normal range. The mean white blood cell count was 7 (IQR 5.2-9.5). Neutrophil count 5.3 (IQR 3.7-7.7), however some patients were mildly lymphopenic, median 0.88 (IQR 0.6-1.2). Most patients had a low CRP, the mean result was 16 (IQR 6.4-26.9). Most patients had a raised ferritin, the mean result was 798 (IQR 411-1515), with 15-400 being considered normal range. Of note lactate dehydrogenase was tested in 70% of the patients and was significantly raised in most patients, the mean being 404 (IQR 300-551) with the normal considered to be 50-242.

A venous lactate was recorded in 44% of patients and all results were normal- <2. The most common comorbidities were hypertension (56.6%), obesity (41.7%) and diabetes (33.8%).

At the study end point 2634 patients had been discharged or had died during hospitalisation. Of these 14.2% were treated in ICU, 12.2% of them received mechanical ventilation, and 21% of these patients died. At the end point of the study of those patients who had received mechanical ventilation 3.3% were discharged alive, 24.5% died, 72.2% were still in hospital. There were no deaths in the under 18 age group (34 patients).

Of the patients who died, those with diabetes were more likely to have received mechanical ventilation or care in the ICU compared to those who did not have diabetes. Interestingly of those who died, those with hypertension were less likely to have received invasive mechanical ventilation than those without hypertension.

As most patients were still in the hospital at the endo point of the study (53.8%) this biases rates toward including patients who died early in their hospital course. The researchers point out that as these patients complete their hospital course, reported mortality rates will decline.

This study was slightly limited by the fact that the data was collected from the electronic heath record database and not the medical notes, from which a greater level of detail may have been established, however it was using this method that allowed for such a large number of patients to have been included and reviewed over a relatively short space of time. It is also limited by the fact that the study population only included patients from within the New York metropolitan area which may underrepresent some ethnic minorities.

Li, HXu, JJournal of Medical VirologyPositive result of SARS-CoV-2 in faeces and sputum from discharged patient with COVID-19 in Yiwu, China20 Apr 2020ChinaAsia0Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.25905
Du, AZhang, ZInfectionClinical characteristics of COVID-19 in children compared with adults in Shandong Province, China16 Apr 2020ChinaAsia14Clinical - Clinical Featureshttps://link.springer.com/article/10.1007%2Fs15010-020-01427-2
Xing, YXing, QJ InfecDynamics of faecal SARS-CoV-2 in infected children during the convalescent phase16 Apr 2020ChinaAsia3Clinical - Clinical Featureshttps://www.journalofinfection.com/article/S0163-4453(20)30177-8/fulltext
Jiang, SYu, XClin Chem Lab MedCoinfection of SARS-CoV-2 and multiple respiratory pathogens in children16 Apr 2020ChinaAsia2Clinical - Clinical Featureshttps://www.degruyter.com/view/journals/cclm/ahead-of-print/article-10.1515-cclm-2020-0434/article-10.1515-cclm-2020-0434.xml
See, K CIbrahim Hinternational journal of infectious diseasesCOVID-19: Four paediatric cases in Malaysia15 Apr 2020malaysia Asia4Clinical - Clinical Featureshttps://www.ijidonline.com/article/S1201-9712(20)30181-8/fulltext
Shi, BXu, HClin PediatrSevere pneumonia due to SARS-CoV-2 and respiratory syncytial virus infection: a case report15 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://journals.sagepub.com/doi/full/10.1177/0009922820920016?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&#articleCitationDownloadContainer
Chen, JHuang, AGenes Dis.The clinical and immunological features of pediatric COVID-19 patients in China14 Apr 2020ChinaAsia12Clinical - Clinical Featureshttps://reader.elsevier.com/reader/sd/pii/S2352304220300507?token=631DD2FAEE11F02D80D1CC96D2AB2621AA7960348DA5FFDD2FAB802D188A0726E724273D5014403A376291F4BD637C50

This early study from Chongqing, China describes the features of 12 children diagnosed with COVID-19. All had a mild course of illness. CT imaging was abnormal in 10 of 12 with patchy ground glass opacity the most common finding. Lymphopenia was present in 2 children.

The authors also compare the "immune profile" (including lymphocyte counts, immunoglobulins, complement, CRP and IL6 levels) of the 12 children with a group of 20 adults patients. Aside from a lower CRP in children (mean 11.5 vs 23.3mg/L) and expected age-related differences in absolute lymphocyte numbers, there were no significant differences between the groups.

liu, J.Lu, B.JMVDetection of SARS‐CoV‐2 by RT‐PCR in anal from patients who have recovered from coronavirus disease 201914 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.25875
Shen, LLan, JJournal of InfectionClinical and laboratory-derived parameters of 199 hospitalized patients with coronavirus disease 2019 in Xiangyang, Hubei Province, China10 Apr 2020ChinaAsia7Clinical - Clinical Featureshttps://doi.org/10.1016/j.jinf.2020.03.038
He, GCai, JIndian PaediatricsSerial Computed Tomography Findings in a Child with Coronavirus Disease (COVID-19) Pneumonia9 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240233/pdf/13312_2020_Article_1824.pdf
Wang, H.Lu, XiaoxiaPediatric Infectious Disease JournalRehospiatlization of a recovered coronavirus disease 19 (COVID-19) child with positive nucleic acid detection9 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://journals.lww.com/pidj/Abstract/onlinefirst/Rehospitalization_of_a_Recovered_Coronavirus.96214.aspx
Lazerrini, MTrobia, GLancet Child and Adolescent HealthDelayed access of provision of care in Italy resulting from fear of COVID-199 Apr 2020ItalyEurope12Clinical - Clinical Featureshttps://doi.org/10.1016/S2352-4642(20)30108-5

This is a report of case studies during the COVID-19 pandemic in Italy of children whose presentations were thought to have been delayed due to parental fears of coming to the hospital. They report from 5 hospitals between March 1st and March 27th 2020, where paediatric presentations were reduced between 73–88%.

During this period, in the week of March 23rd to 27th 12 children are identified whose parents reported avoiding accessing hospital due to concerns over SARS-CoV-2 infection . 6 of these were admitted to PICU and there were 4 deaths. The cases include 2 children with DKA, 2 with acute leukaemia, 2 children with cerebral palsy and complex needs, 1 with pneumonia and febrile convulsions, 1 with pyelonephritis, 1 with pyloric stenosis, 1 with a Wilm’s tumour, 1 with vomiting and hypoglycaemia and 1 with a congenital syndrome on dialysis.

This case series highlights the concerns of many paediatricians that more deaths will be seen in children from collateral damage born from the COVID-19 response, than will die of COVID-19. Delayed presentations is a major concern around the world currently, and whilst these cases certainly raise concerns, evidence is needed to ascertain the true presence and extent of this problem.

Zhu, CZhu, LPediatric PulmonologyClinical characteristics of a case series of children with coronavirus disease 20198 Apr 2020ChinaAsia10Clinical - Clinical Featureshttps://doi.org/10.1002/ppul.24767

This is a case series of ten paediatrics patients aged 1 – 17 years with confirmed Covid 19. These cases were retrospectively selected from 3 hospitals in Jiangsu, a coastal province approx 700 km east of Wuhan. Cases were collect from 24th January 2020 to 22nd February 2020. All cases were confirmed by RT-PCR anal or throat swabs. 70% of children presented with symptoms, and 30% were asymptomatic, but were screened due to contact with confirmed family member.

The most common symptoms on presentation were fever (40%), cough, (20%) and headache (20%). There was no report of whether children had underlying conditions. All children had a CT chest completed. Half of the cohort had CT changes. There were 2 cases of bilateral pneumonia, and 3 cases of unilateral pneumonia, 2 of which were in asymptomatic patients. Bloods were unremarkable, one child aged 1 year had Lymphocytosis, all others had normal lymphocyte counts. CRP was not raised in any child. Only one patient in the cohort required oxygen, and there were no ICU admissions. Five children were treated with antiviral medication including lopinavir/ritonavir (n=4) interferon α‐2b (n = 4), and oseltamivir (n = 1).

Of note, 5 children were still in hospital at the end of the case series.

Yuan, JLiu, LClinical Infectious DiseasesPCR assays turned positive in 25 discharged COVID-19 patients8 Apr 2020ChinaAsia6Clinical - Clinical Featureshttps://doi.org/10.1093/cid/ciaa398
Shen, QZhou, ZPediatric PulmonologyNovel coronavirus infection in children outside of Wuhan, China7 Apr 2020ChinaAsia9Clinical - Clinical Featureshttps://doi.org/10.1002/ppul.24762

This retrospective study examines the clinical characteristics of children admitted to Public Health centre of Changsha, Hunan, China. There were 9 children admitted during the study period 08/01/2019 and 19/02/2020 who tested positive for COVID-19. All had a confirmed contact case with COVID-19. Median age was 8 years, with a minimum age 1 year and oldest was 12 years. Children were predominantly female (6/9, 66%). There was no information provided about co-morbidities.Clinical features: 2/9 were asymptomatic, 1/9 had cough, 4/9 had fever, 1/9 had sore throat and 2/9 had diarrhoea.

Radiology: 2 patients had chest CT that were described as ground glass opacities. No further information was provided about the indications.

Bloods: 1/9 had lymphocytosis in whom other infectious causes were excluded. 1/9 had raised CRP, 4/9 raised ESR, 1/9 raised LDH, 2/9 had raised AST with 0/9 ALT abnormalities. All abnormalities were mild.

Treatments: All (9/9) children were treated10/2.5 mg/kg lopinavir/ritonavir twice daily, orally. 5/9 children received 10 mg/kg azithromycin once a day. One child received meprednisone and immune globulin therapy for febrile convulsion. No additional information regarding treatments were provided.All children required oxygen therapy. None required intensive care or mechanical ventilation.Outcomes: At the end of data collection 3/9 remained under hospital care and were positive for COVID-19. The remainder (6/9) were discharged from hospital. The time spent in hospital varied between 11 and 22 days (median 13.5 IQR 10.75-14 days).

Other salient features: 6/9 children were RT-PCR negative at discharge. The time between initial contact and a negative test varied between 9 and 20 days (median 13.5 IQR 10.75-14 days).

All averages were calculated by the reviewer from the data provided within the article.

Lei, PJiao, JJournal of X-ray Science and TechnologyClinical and computed tomographic (CT) images characteristics in the patients with COVID-19 infection: what should radiologists need to know?7 Apr 2020ChinaAsia1Clinical - Clinical Featureshttps://content.iospress.com/articles/journal-of-x-ray-science-and-technology/xst200670
Han, YFang, YJournal of Medical VirologyA comparative-descriptive analysis of clinical characteristics in 2019-coronavirus-infected children and adults6 Apr 2020ChinaAsia7Clinical - Clinical Featureshttps://doi.org/10.1002/jmv.25835

This retrospective study compares the clinical characteristics of 25 adults and 7 children with acute respiratory disease confirmed as COVID-19. Cases were retrospectively identified from patients admitted to Xian Eighth Hospital in Shaanxi, China, between 31st January and 16th February 2020. The mean age of the children was 1.3 years with a range of 2 months to 13 years, and 4 (57%) were male. None had any co-morbidities.

Clinical features: 5/7 (71%) children had cough, 3/7 (43%) had shortness of breath, 5/7 (71%) had fever, 1/7 (14%) had sore throat and 4/7 (57%) had diarrhoea and/or vomiting.

Radiology: 5/7 (71%) children had “positive findings suggestive of pneumonia” reported on CXR and/or CT. Examples of these findings were ground glass opacities and segmental consolidation in bilateral lung fields, particularly peripherally.

Bloods: No children had a low lymphocyte count (<0.8). Raised lymphocyte counts were not mentioned but raised WCC was reported in 2/7 (29%) children. 2/7 (29%) had a raised CRP (>10). 4/7 (57%) had a raised AST (>50) or ALT (>37). 5/7 (71%) had increased Brain Natriuretic Peptide (>125). 4/7 (57%) had a raised CK Isoenzyme (>30).

Outcomes: All 7 cases in children were classified as mild and recovered within 1-2 weeks. None of the children were admitted to intensive care and none died.Comparison of clinical characteristics in adults and children: Children were more likely than adults to have diarrhoea and/or vomiting (57% vs. 8%, p=0.012). Adults more frequently had a reduced WCC, compared to a raised WCC in children, and raised CK isoenzyme was less common in adults.

Graselli, GPasenti, AJAMABaseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy6 Apr 2020ItalyEurope4Clinical - Clinical Featureshttps://jamanetwork.com/journals/jama/fullarticle/2764365

This is a retrospective case series of 1591 consecutive patients with laboratory-confirmed COVID-19 referred for ICU admission to the regional ICU coordinator of the Lombardy ICU Network, and treated at one of the ICUs of the 72 hospitals in the network. Patients were recruited between 20/02/2020 and 18/03/2020 with follow-up on 25/03/2020. Data was collected via telephone. Of the nearly 1600 patients referred for ICU admission, only 4 were between 0 and 20 years of age, with a median age of 16 and interquartile range of 14 to 19 years of age. Three of the four patients (75%) were male and three of the four had comorbidities (specific details not given).

Two required mechanical ventilation. It’s important to note that the patients in this study were those admitted to ICU and not patients on medical wards, in the ED or in the community so the high percentage of ventilated patients in this study is not a reflection of the other patients in the region with SARS-CoV-2. These two patients had relatively low oxygen requirements with an FiO2 of 30% and 50%; relatively low PEEPs of 5 and 14 mmHg; and favourable PaO2/FiO2 ratios of 195 and 323, placing these two patients in the mild to moderate ARDS severity scores (for more information on PaO2/FiO2 ratios have a look at the LITFL explanation at https://litfl. com/pao2-fio2-ratio/). None of the four patients in the 0-20 year old category received ECMO. Information on disposition was only available for two of the four patients. None of these patients died. Two remained on ICU on 25/03/2020 at time of follow-up.What can we take from this study? As the study recruited patients admitted to ICU, the numbers of adolescent patients in this case series is low at only four, with an age range of 16 to 19. The data was collected retrospectively via telephone making it difficult to draw robust conclusions. However, we can see that compared to the older groups of patients in the study, ventilation requirements were lower. Three of the four adolescent patients had comorbidities, which might suggest that children and adolescents without comorbidities in the Lombardy region were less severely unwell and did not require ICU admission.

Lai, WLiu, JPediatr RadiolComputed tomography of the lungs in novel corona virus (COVID-19) infection6 Apr 2020ChinaAsia2Clinical - Clinical Featureshttps://doi.org/10.1007/s00247-020-04664-7
Canarutto, DBarera, GPediatric PulmonologyCOVID-19 infection in a paucisymptomatic infant: raising the index of suspicion in epidemic settings6 Apr 2020ItalyEurope1Clinical - Clinical Featureshttps://doi.org/10.1002/ppul.24754

This early single case report from Milan, Italy describes an infant with mild a mild case of COVID-19 who recovered without need for intervention. His father, the implied household index, had an upper airway infection with conjunctivitis without confirmatory testing.

Patient: 32 day old boy, presented to hospital symptomatic

Clinical Features: Cough, fever, rhinitis

Radiology: CXR normal

Bloods: reactive lymphocytes on film, monocytosis (1400/L) and neutrpenia (900/uL), CRP normal

Outcomes: Resolution of fever by day 3 of hospitalisation, full recovery without need for supportive therapy. Breast feeding maintained.

Lin, LShan, HGutGastrointestinal symptoms of 95 cases with SARS-CoV-2 infection2 Apr 2020ChinaAsia5Clinical - Clinical Featureshttps://gut.bmj.com/content/early/2020/04/02/gutjnl-2020-321013
Xing, YXing, QJournal of Microbiology, Immunology and Infection.Prolonged viral shedding in feces of pediatric patients with coronavirus disease 201928 Mar 2020ChinaAsia3Clinical - Clinical Featureshttps://dx.doi.org/10.1016%2Fj.jmii.2020.03.021
Yin XLi HRadiology of Infectious Diseases A mild type of childhood COVID-19 - a case report27 Mar 2020ChinaAsia1Clinical - Clinical Featureshttps://doi.org/10.1016/j.jrid.2020.03.004
Qui, HLancet: Infectious DiseasesClinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study25 Mar 2020ChinaAsia36Clinical - Clinical Featureshttps://doi.org/10.1016/S1473-3099(20)30198-5

Qui and colleagues retrospectively identified 36 children with an EMR diagnosis of COVID-19, during the period Jan 17 through March 1st, at three hospitals in Zhejiang, China, a province 900km to the east of Wuhan. Diagnosis was made by COVID-19 RT PCR for all patients presenting with fever, cough and radiographic presentation, or if there was a history of exposure to an infected individual.

For the mild cohort, 28% of patients were asymptomatic, with moderate cases more likely to have fever of 38oC or higher (47%), cough (24%), vomiting or diarrhoea (10%) or headache (10%). More than half (53%) of patients had ground-glass opacities on CT scan, meeting the case definition for Moderate illness. Key laboratory values of note include lymphopaenia, leukocytopaenia and increased procalcitonin as all associated with moderate illness. No patients in this cohort were hypoxaemic as a result of their pneumonia.

The authors also draw comparisons between adults and children with COVID-19 (less severe illness, less likely to have abnormal investigations), as well as comparing the clinical features and severity of COVID-19 with SARS (milder symptoms and severity) and H1N1 influenza (fewer symptoms, more frequent pneumonia) in children. Wisely, Qui & colleagues note the high rate of findings that are not clinically obvious, and the high proportion of asymptomatic cases make for very challenging case identification in the absence of clear epidemiologic information. “This finding suggests a dangerous situation if community-acquired infections occur.”

Su, LGai, ZEmerging Microbes and InfectionsThe different clinical characteristics of corona virus disease cases between children and their families in China - the character of children with COVID-1925 Mar 2020Asia9Clinical - Clinical Featureshttps://www.tandfonline.com/doi/full/10.1080/22221751.2020.1744483

This study from the Jinan Infectious Disease Hospital retrospectively reviewed cases of nucleic acid-positive SARS-CoV-2 patients between 24th January to 24th February 2020 (detected using the (ORF1ab/N) nucleic acid detection kit by Bio-germ, Shanghai, China). Nine children and members of their family totalling 14 adults were included. Note that two family members missed enrollment as they were at another hospital. Of the 9 children, 6 were female (66%). The age group ranged from 11 months to 9 years and 9 months old (mean age 4.5 years). For eight of the nine children, there was history of their parents having travelled frequently, being in contact with someone from Wuhan or having worked or visited Wuhan. Of note, five of the discharged children were readmitted to hospital because their stool showed positive results in SARS-CoV-2 PCR.

Clinical Features (children): 3 of the 9 children had fever (33%) and one had cough (11.2%). Imaging (children): On chest x-ray and CT, two children had findings consistent with bronchitis (22.2%), one had bronchial pneumonia (11.1%) and a further one had pulmonary consolidation and ground glass opacity. From the two example images included,, findings appear to be bilateral but this was not specified in the body of the text. Bloods (children): 8 of 9 children (88.9%) had normal or decreased white blood cell counts. Six children (66.7%) had increased CK-MB. ALT, AST. All children had a normal CRP, PCT, ESR and IL-6. Clinical Features (adults): Of the 14 adults, 8 (57.1%) had fever, five had cough (35.7%), three had chest tightness or pain (21.4%), a further three had fatigue (21.4%) and one reported a sore throat (7.1%). Imaging (adults): Ten (71.4%) had abnormal imaging mainly pulmonary consolidation, with 7 (50%) having nodular shadow and 7 (50%) having ground glass opacities. Bloods (adults): Four (28.6%) had reduced whice cell count with seven (50%) having lymphocytopaenia.

Zheng, FJin, RCurrent Medical ScienceClinical characteristics of children with coronavirus disease 2019 in Hubei, China24 Mar 2020ChinaAsia25Clinical - Clinical Featureshttps://doi.org/10.1007/s11596-020-2172-6

This is a retrospective case series of 25 children <14 years of age hospitalised with COVID-19 from 10 hospitals across the Hubei province between February 1st and February 10th 2020. It is unclear how the cases were ascertained. 14/25 were male (54%) and the median age was 3yrs (IQR 2-9yrs). Most patients were <3 years (40%). 2 patients had a background of repaired congenital heart disease (both infants), although we have no more detail than this. Both of these children went on to develop critical illness.Clinical features: 13/25 (52%) had fever, 11/25 (44%) had cough, 3/25 (12%) had diarrhoea, and 2/25 (8%) had nasal congestion, vomiting, breathlessness or abdominal pain.

Bloods: Inflammatory markers were not particularly raised, with a median CRP of 14.5mg/L (IQR 0.93 - 25). 10/25 (40%) patients had lymphopenia.

Radiology: CT chest was normal in 8/24 (32%) with unilateral involvement in 5/24 (20%) and bilateral in 12/24 (48%). Changes typically showed patchy shadows. Younger children appeared more likely to have bilateral lung findings than older children.

Co-infection: Other organisms identified included Mycoplasma pneumoniae (3/25, 12%), Influenza B (2/25, 8%) and one of the 2 critically ill children had Enterobacter aerogenes.

Lou, XTian, YJournal of Paediatrics and Child HealthThree children who recovered from novel coronavirus 2019 pneumonia22 Mar 2020ChinaAsia3Clinical - Clinical Featureshttps://doi.org/10.1111/jpc.14871

This is a case series of 3 children diagnosed with COVID-19 and admitted in the Zhengzhou University Children’s hospital in Henan Province, China (dates not provided). They were 2 sisters aged 6 and 8yrs, and a 6m old infant. The children were all infected by a family member, although the family of the 6m infant had no link to Wuhan.

Clinical features: All 3 had a fever, 2 had nasal congestion and rhinitis alongside fatigue, diarrhoea, and headache. The 6yr old girl had a cough.

Radiology: All 3 patients had CT scans with bilateral infiltrates

Bloods: Not reported

Outcomes: No children required intensive care/intubation or had any severe complications. All have been discharged. The 2 sisters were treated with nebulized interferon.

Liu HLan WJournal of InfectionClinical and CT imaging features of the COVID-19 pneumonia: Focus on pregnant women and children21 Mar 2020ChinaAsia4Clinical - Clinical Featureshttps://doi.org/10.1016/j.jinf.2020.03.007

This study is a review of CT imaging findings in children and pregnant women in a hospital in the Hubei Province. Four children with confirmed COVID-19 infection were included in the study. The bottom line is that pulmonary CT changes in children were mild, with either focal ground glass opacification or focal consolidation. Although CT has been reported as a useful screening tool in adults with suspected COVID-19 infection, the CT changes of the four children were non-specific; the authors conclude that exposure history and clinical symptoms are more helpful for screening in swab-negative children than CT. 41 pregnant women with either laboratory-confirmed or clinically-diagnosed COVID-19 infection were included in the study. All pregnant women had mild courses of their COVID-19 illnesses. Six of the 16 laboratory-confirmed pregnant women and 10 of the 25 clinically diagnosed pregnant women delivered during the study period. There were no cases of vertically transmitted COVID-19 in the neonates born to these pregnant women.

Case 1: 5 year old female with fever, cough and fatigue. No lymphadenopathy. Bloods: low WCC with raised lymphocytes and decreased neutrophil ratio. Normal CRP. CT: normal. Follow-up CT 9 days later remained normal.

Case 2: 11 month old male with fever and cough. No lymphadenopathy Bloods: normal WCC with raised lymphocyte count and decreased neutrophil ratio. Normal CRP. CT chest: single consolidation without peripheral predominance (unlike reported findings in adults).

Case 3: 9 year old female with fever but no cough. No lymphadenopathy. Bloods: normal WCC, low lymphocytes and normal neutrophil ratio. Normal CRP. CT chest: single ground glass opacity without peripheral predominance (unlike reported findings in adults).

Case 4: 2 month old male with cough but no fever. No lymphadenopathy. This infant was coinfected with RSV. Bloods: normal WCC with normal lymphocytes and normal neutrophil ratio. CRP raised (does not say how high). CT chest: multiple focal consolidations and pleural effusion. This infant’s CT findings were more severe than the other three children, thought to be due to coinfection with RSV.

Lu, XWong, GWKNEJMSARS-CoV-2 infection in children18 Mar 2020ChinaAsia171Clinical - Clinical Featureshttps://www.nejm.org/doi/full/10.1056/NEJMc2005073

This retrospective study examines the clinical characteristics of children with confirmed COVID-19 diagnosed at Wuhan Children’s hospital. There were 1391 children tested between Jan 28th and Feb 26th 2020 due to known contact with a case of COVID-19, of these 171 were confirmed to have SARSCoV-2. Median age was 6.7yrs, and there was a relatively even spread amongst age groups. Children were predominantly male (104/171, 60.8%).

Clinical features: 83/171 had cough, 79/171 had pharyngeal inflammation (sore throat), 71/171 had fever. 15/171 had diarrhoea and 13/171 had rhinorrhoea. 49/171 were tachypnoeic on admission and 72/171 were tachycardia. Only 4/171 had Oxygen saturations <92% during hospitalisation. 0/31 infants <1yr were asymptomatic in this cohort, with rates of asymptomatic infection increasing with age. There were higher rates of pneumonia in infants (25/6), but the definition of this is unclear. We also have no information regarding co-infection with other viruses or bacteria.

Radiology: Not delineated into CXR or CT, but descriptions sound like CT findings. The most common was bilateral ground glass opacity (56/171) followed by unilateral patchy shadowing (32/171) and bilateral patchy shadowing (21/171). There were several children with radiographic pneumonia who were asymptomatic.

Bloods: The supplementary appendix contains lab results. Only 6/171 patients had lymphopaenia, the vast majority were in normal range (Med 2.9×109/L, IQR 2.2 – 4.4). CRP was elevated (>10mg/L) in 33/171 (Med 4, IQR 1.3 – 8) of which 27/33 had pneumonia.

Outcomes: 3 patients required ITU admission and intubation. All 3 had comorbidities, including hydronephrosis, leukaemia and intussusception. The child with intussusception suffered multiorgan failure and died after 4 weeks. The cause of death is not clear from the report. As of writing 149 patients had been discharged with 21 stable in the general wards.

Cui, YZha, YJournal of Infectious DiseasesA 55-day-old female infant infected with 2019 novel coronavirus disease: presenting with pneumonia, liver injury, and heart damage17 Mar 2020ChinaAsia1Clinical - Clinical Featureshttps://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiaa113/5807961

This is a case report of a 55 day old with SARS-CoV-2 who was admitted to hospital in China on February 2, 2020. She was treated with inhaled intereron-alpha-1b, amoxicillin, reduced glutathione, ursodeoxycholic acid, and traditional Chinese medicine lotus qingwen. The child was initially well, although her respiratory status worsened on day 2-6, and she required supplemental oxygen via nasal cannulae. Anal swabs on day 11 and 13 were positive on day 11-13 despite negative pharyngeal swabs.Note is made in the title of this study that the infant sustained liver injury and heart damage. This is on the basis of marginally elevated liver tranaminases and cardiac troponin measurements, for which it is unclear why the tests were performed. There is no indication of any clinical compromise demonstrated. It should be noted that a significant proportion of the child’s care (including investigations) would not be considered standard practice in UK/US/Aus paediatric medicine.

Zhang, CZhou, XMedRxIVClinical characteristics of 34 children with coronavirus disease-2019 in the West of China: a multiple-center case series16 Mar 2020ChinaAsia34Clinical - Clinical Featureshttps://www.medrxiv.org/content/10.1101/2020.03.12.20034686v1

A pre-print, the information should be treated with caution until it has undergone peer review.This is a further retrospective case study looking at 34 children with confirmed COVID-19 between Jan 1st and Feb 25th 2020 in 4 hospitals in Western China. They were aged 1 month to 12 years.

Clinical features: The most common symptom was fever (26/34) followed by cough (20/34), followed by vomiting (4/34) and diarrhoea (4/34). A significant number had co-infections (16/34) including Mycoplasma pneumoniae (9/34), influenza A or B (12/34) and 2/34 were mononucleosis. One child had a nephroblastoma and one had asthma. The median incubation period was 10 days (IQR 7.75 – 25.25) and median 3 days (IQ 2 – 4) from admission to fever resolution

Bloods: Lymphocytosis was most common (17/34). CRP was not significantly elevated (median 7.56ml/L, IQR 1.21 – 15.13), but was >5 for 20/34, and procalcitonin was not significantly elevated either (0.6, 0.03 – 0.07)

Radiography: On chest CT 14/34 had patchy shadows bilaterally, 14/34 unilaterally, and 6 had normal CT chest.

Ji, LJian, RWorld Journal of PediatricsClinical features of pediatric patients with COVID-19: a report of two family cluster cases16 Mar 2020ChinaAsia2Clinical - Clinical Featureshttps://dx.doi.org/10.1007/s12519-020-00356-2

This is a review of two confirmed paediatric cases of COVID-19 (both from oropharyngeal swabs) from two family clusters with recent travel to Wuhan. One child presented with fever and the other with diarrhoea.

Case one: 15-year-old boy presenting with a one-day history of fever. Clinical features: Temperature 37.9oC, pharyngeal congestion. Normal lung auscultation. Laboratory findings: mildly elevated white cell count at 11.82 x109/L, predominantly neutrophils (67.3%) and 25.7% lymphocytes. His CRP was mildly elevated at 35 mg/L. Radiological findings: normal unenhanced CT chest. Outcome: Symptomatic treatment. Symptoms disappeared after two days. Family information: both parents also tested positive for SARSCoV2.

Case two: 9-year-old boy presented with mild diarrhoea but no cough and no fever. Normal examination. Laboratory findings: normal white cell count and normal CRP. Radiological findings: normal unenhanced CT chest. Outcome. Treated with oral probiotic and symptoms disappeared after 2 days. Family information: Family members had negative COVID-19 swabs but were symptomatic. His mother presented with fever and cough with bilateral peripheral ground glass opacifications on CT chest. The child’s father and two-year old sister had normal CT chests but had mild symptoms consistent with COVID-19: his father had a cough for four days and his twoyear-old sister had a transient two-day low-grade fever.

Xu, YGong, SNature MedicineCharacteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding13 Mar 2020ChinaAsia10Clinical - Clinical Featureshttps://doi.org/10.1038/s41591-020-0817-4

This study presents the results of widespread screening for COVID-19 in Guangzhou in China. 745 children were screened of which 10 were positive for COVID-19. Their ages ranged from 2 months to 15 years.

Clinical features: 6/10 had a fever over 38oC. 5/10 had a cough. 4/10 had a sore throat. 2/10 had rhinorrhoea and 2/10 had diarrhoea.

Radiography: 7/10 had coarse lung markings on CXR with no pneumonia, and 3/10 were normal. CT scans revealed ground glass or patchy opacities in 5/10.Bloods: Basically normal in all cases

They made note that rectal swabs were frequently positive and that these swabs were positive for a longer duration than nasal swabs. The authors suggest on this basis that faecal-oral transmission may be possible, however this is very uncertain and will require further research to elucidate.

Liu, WLiu, YNEJMDetection of COVID-19 in children in early January 2020 in Wuhan, China12 Mar 2020ChinaAsia6Clinical - Clinical Featureshttps://doi.org/10.1056/NEJMc2003717

This letter to the editor describes a case series from Tongji hospital in Wuhan, China, taken from a cohort of 366 hospitalized children between January 7th and 15th 2020. 6 children were PCR Positive for COVID-19. Of the 6 patients, age range 1-7 years. All had fever >39oC, cough and 4/6 had vomiting. All had lymphocytopenia, with 4/6 leukopenia and 3/6 with neutropenia. One child required an ICU admission, receiving pooled donor IVIG. The median recovery time was 7.5 days. Authors surmise COVID-19 occurs in children with some moderate-severe episodes of illness.

Li, WLi, SPediatric RadiologyChest computed tomography in children with COVID-19 respiratory infection11 Mar 2020ChinaAsia5Clinical - Clinical Featureshttps://doi.org/10.1007/s00247-020-04656-7

This study describes five children with confirmed COVID-19 who had CT chest scans in a large tertiary level hospital in China. Three of the five children had patchy ground-glass opacities on their CT scans but these changes were less severe than those seen in infected adults. The treatment is not detailed in the paper, so presented as published in this summary.

Case 1: 17 month old asymptomatic male. Bloods: CRP 9.4, WCC 9.2. Radiology: CT chest performed on day 4 showed patchy ground glass opacities. Repeat CT on day 9 after treatment had normalised (antiviral, anti-infective, immunoglobulin, interferon and Lianhua qingwen granules). No CXR.

Case 2: 10 month old asymptomatic female. Bloods: CRP 0.9, WCC 14.8. Radiology: Day 2 scan: normal. Not repeated. No CXR.

Case 3: 3 year old male with coryza, productive cough, sore throat and fever after 3 days. Bloods: CRP 0.7, WCC 15.0. Radiology: Day 9 CT showed patchy ground-glass opacities. Repeat CT on day 16 had normalised after treatment (antiviral, anti-infective, immunoglobulin). No CXR.

Case 4: 4 year old asymptomatic male. Bloods: CRP 0.2, WCC 6.6. Radiology: Day 2 CT chest showed patchy ground-glass opacities. Repeat CT on day 7 had normalised after treatment (montelukast, immunoglobulin). No CXR.

Case 5: 6 year old asymptomatic male. Bloods: CRP 0.6, WCC 5.3. Radiology:

Day 3 CT was normal. No CXR.

Xu, R.Hu, XQuantit Imag Med and SurgCT imaging of one extended family cluster of corona virus disease 2019 (COVID-19) including adolescent patients and "silent infection" 10 Mar 2020China Asia1Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136726/
Xia, WHu, DPediatric PulmonologyClinical and CT features in pediatric patients with COVID-19 infection: different points from adults5 Mar 2020ChinaAsia20Clinical - Clinical Featureshttps://doi.org/10.1002/ppul.24718

A case series of 20 paediatric patients with COVID-19 infection identified with COVID-19 NAT on pharyngeal swabs from Wuhan Children’s Hospital. It reviews the clinical information and co-infections.

Clinical features: two thirds had a clear contact history. Incubation 24hrs28 days of life. 13/20 had a cough, 12/20 had a fever. Bloods: 11/20 had (N) CRP, i.e. less than 3mg/L and 80% had PCT >0.05.

Radiology: On CT: Subpleural findings were seen in all 20 patients. 50% had bilateral findings, with a further 6/20 with unilateral findings. Consolidation with a halo in 50% of cases, considered as atypical signs in paediatric patien. Chloral hydrate was the primary sedative for CTs These were predominantly mild cases in the paediatric patients, with CXR adding little diagnostically. An early chest CT exam seemed to be necessary. 9/20 had coinfection, most commonly with mycoplasma (4/9) – although the ‘flu B,’flu A or RSV accounted for almost all of the remainder

Despite this, the physical chest symptoms were mild, with retraction in one case, and another case with cyanosis.

The average length of stay 12.9 days. Some patients were managed on the basis of their CT alone. These are similar to those seen in adults.

Lan, L.Xu, H. Korean J Radiol Early CT Findings of Coronavirus Disease 2019 (COVID-19) in Asymptomatic Children: A Single-Center Experience.4 Mar 2020China Asia4Clinical - Clinical Featureshttps://kjronline.org/Synapse/Data/PDFData/0068KJR/kjr-21-919.pdf
Zhu, YFeng, SJournal of Infection Clinical and CT imaging features of 2019 novel coronavirus disease (COVID-19)3 Mar 2020ChinaAsia1Clinical - Clinical Featureshttps://doi.org/10.1016/j.jinf.2020.03.033
Kai-qian, KThoon, KCClinical Infectious DiseasesA well infant with coronavirus disease 2019 with high viral load28 Feb 2020SingaporeAsia1Clinical - Clinical Featureshttps://doi.org/10.1093/cid/ciaa201

This was a case report of a single 6-month-old with a positive nasopharyngeal swab until D16 of admission to hospital. There had been household transmission. There was a positive NPA with rt-PCR on D1 of admission although the child was asymptomatic – daily swabs remained positive until D17. The child was febrile once during the course of admission although they remained asymptomatic. Blood and stool tests were positive on D2.

They had essentially normal investigations except for a neutropenia.

Cai, JZeng, MClinical Infectious DIseasesA case series of children with 2019 novel coronavirus infection: clinical and epidemiological features28 Feb 2020ChinaAsia10Clinical - Clinical Featureshttps://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa198/5766430

This retrospective study examines 10 children diagnosed with confirmed COVID-19 between 19th Jan and 3rd February 2020 at the Children’s hospital in Shanghai. The age range is from 3 months to 11 years. None had comorbidities. There were no severe cases.

Clinical features: The assumed incubation period (time from exposure to index case to developing symptoms) was between 2 – 10 days, but median (and mode) 7 days. With regard to symptoms, 7/10 had fever >38oC, 6/10 had a cough, 4/10 had a sore throat, 3/10 had nasal congestion, 2/10 had rhinorrhea and 2/10 were sneezing.

Radiology: The chest x-ray was normal in 6/10. The rest had unilateral opacities.

Bloods: Lymphocyte counts were normal in 9/10, raised in one case. CRP ranged from 0.5mg/L to 35mg/L but was <10 for 7/10. Procalcitonin was normal (<0.25) in all children. 2 patients had a mild elevation of ALT (100U/L) or AST (142U/L and 51U/L) Detection of SARS-CoV-2: Virus was found in NP/throat swabs in all patients, and the duration of shedding ranged from 6-22 days (Median 12 days). Stool shedding was prolonged, over 30 days in one patient. No urine was positive, and no serum positive.

Chen, CWang, FLancet pre-print serverCoronavirus disease-19 among children outside Wuhan, China25 Feb 2020ChinaAsia31Clinical - Clinical Featureshttp://dx.doi.org/10.2139/ssrn.3546071

A pre-print, the information should be treated with caution until it has undergone peer review. This is a prospective case series of 31 paediatric cases of COVID-19 diagnosed at the Shenzen Third Peoples hospital between Jan 16th and Feb 19th 2020. This made up 7.9% of all cases diagnosed in Shenzen. They were all confirmed by PCR. None had been exposed to the seafood market in WUhan. The patients received nebulised interferon and, IV ribavirin or oral lopinovir/ritonavir. The median age was 6.75, with most patients (41.9%) aged 5-9. Followed by 0-4yrs (32.2%) and 10-14yrs (19.4%). 41.9% were male.Clinical features: 12/31 Children were asymptomatic. Fever was observed in 14/31, Cough in 13/41, Sore throat in 2/31, Rhinorrhoea in 22/31 and diarrhoea in 2/31. Median duration of fever was 2 days, with a range of 1–9 days. Bloods: Lymphopaenia was not observed. Lymphocytosis occurred in 17/31 patients. CRP was elevated in 4/31 patients. Radiology: On admission 64.5% of CT were normal, with 25% having unilateral pneumonia and 9.7% having bilateral. During hospitalization one child developed a unilateral pneumonia whose radiography was initially normal. Outcome: 23 children had been discharged at the time of writing, and the remainder were well and afebrile.

Xu, XWLi, LJBMJClinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-CoV-2) outside of Wuhan, China: a retrospective case series19 Feb 2020ChinaAsia2Clinical - Clinical Featureshttps://www.ncbi.nlm.nih.gov/pubmed/32075786

This study looks at a group of 62 patients with COVID-19 in a province outside of Wuhan (Hubei). 2 of these were children, aged 10 and 11. There is a lot of clinical data in the paper but it is not broken down by age, so we cannot make any inference on behalf of the paediatric patients.

Wei, MLiu, YJAMANovel coronavirus infection in hospitalized infants under 1 year of age in China14 Feb 2020ChinaAsia9Clinical - Clinical Featureshttps://doi.org/10.1001/jama.2020.2131

This is a case series of, from Dec 8 2019 to Feb 6 2020, from China of 9 infants – all of whom had been hospitalised.

Clinical presentation: 4/9 fever, 2/9 mild URTI symptoms, 1/9 were asymptomatic. All had family members that were COVID-19 positive. There were no severe complications or ICU admissions.

Kabesch Msingle authorPed Allergy ImmunologyShielding against SARS‐Cov‐2 infection is not justified in children with severe asthma5 Aug 2020EuropeEurope0Clinical - Comorbiditieshttps://doi.org/10.1111/pai.13327

In the UK, severe asthma was one of the diagnoses which mandated ‘shielding’, i.e. remaining at home at all times, during the lockdown, for children and adults. Some doubted whether this was necessary. This brief report suggests that the doubters were right. Using a database which was originally designed to monitor the use of biologic treatments in severe asthma, the author surveyed 37 major asthma centres in 25 European countries. None of the centres were aware of any symptomatic COVID-19 case from March-July 2020 in any of the roughly 1000 children included.

So was this because shielding prevented it? No, because they compared the 4 countries with strict shielding policies (including the UK) with the others where precautions for asthmatics were the same as everyone else. There was no difference.They conclude that shielding is unnecessary, even in the most severe asthmatics.

Wilkes, MRapaport RJ of PediatricsSevere COVID-19 in Children and Young Adults.23 Jun 2020USANorth America10Clinical - Comorbiditieshttps://www.jpeds.com/article/S0022-3476(20)30764-2/pdf
Kulkarni, RKJadhav, TIndian Journal of PaediatricsFatal Covid-19 in a Malnourished Child with Megaloblastic Anemia17 Jun 2020IndiaAsia1Clinical - Comorbiditieshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297666/
Yuksel, MAriKan, CEur J Gastroenterol HepatolImmune monitoring of a child with autoimmune hepatitis and type 1 diabetes during COVID-19 infection16 Jun 2020TurkeyMiddle East1Clinical - Comorbiditieshttps://journals.lww.com/eurojgh/Abstract/9000/Immune_monitoring_of_a_child_with_autoimmune.97545.aspx
Akcabelen, Y. M.Yarali, N.Pediatr Blood Cancer: e28443.COVID‐19 in a child with severe aplastic anemia15 Jun 2020TurkeyMiddle East1Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/full/10.1002/pbc.28443?af=R
Cesaro, S.Petris, MGPaediatr Blood CancerScreening for SARS-CoV-2 infection in pediatric oncology patients during the epidemic peak in Italy15 Jun 2020ItalyEurope282Clinical - Comorbiditieshttps://doi.org/10.1002/pbc.28466

Observational study of nasopharyngeal presence of SARS-CoV-2 in a cohort of 282 paediatric oncology patient presenting for scheduled care at 14 specialist centres in Italy between 20/02/20 and 19/04/20. Median age for oncology cases (n=247) was 7 years (range 0-17.9) and for stem cell transplant (SCT) patients (n=35) was 9.6 years (range 0.3-17.6). 10/334 swabs from the oncology group were +ve and 0/56 from the SCT group. Only 2/10 NPS +ve patients had any symptoms (both "mild fever").

Chemotherapy was paused for all NPS +ve patients until 2 clear swabs were obtained 24 hours apart. No adverse outcomes were recorded up to the study end but follow up was only reported up to 30/04/20. This study demonstrates that paediatric oncology patients can remain asymtomatic whilst carrying SARS-CoV-2 in the nasopharynx, and recover spontaneously, without any apparent increased rate of adverse outcomes. Researchers raise the question of whether routine chemotherapy needs to be paused for asymptomatic NP carriage of SARS-CoV-2 but present no evidence for the safety of this course of action.

Flores, VLenica A, CAnn Hematol.SARS-CoV-2 infection in children with febrile neutropenia12 Jun 2020MexicoSouth America3Clinical - Comorbiditieshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289627/

This letter to Annals of Hematology offers a brief description of three children with ALL who presented with febrile illness and were found to be SARS-CoV2 PCR positive. The letter is of note as sadly one of the children died during this illness following cardiac arrest; the authors offer the paper to highlight the occurrence of SARS CoV2 in febrile neutropenic patients; however it prompts further analysis of those cases of severe infection in the context of immunosuppression.

The patients were identified at a centre in Mexico however the time period is not known. The three patients were aged 4yrs, 8yrs and 9yrs. All had ALL, two receiving consolidation chemotherapy and one on immunosuppression with mycophenolate and prednisolone. The latter patient had undergone HSCT for ALL, the time since HSCT was not provided, however this patient was admitted from the community suggesting she wasn’t in the immediate post-transplant period. All patients developed neutropenia either at time of fever or quickly following it and similarly evolved to have ‘respiratory symptoms’. All had negative blood cultures however results of other virology is not provided. Over-all pre-covid health status is not provided within the letter and this might be helpful in understanding the severity of symptoms in the patient who died.

The child who died was 8 years old and presented with febrile neutropenia, they were on mycophenolate and prednisolone following HSCT for ALL. The child quickly developed respiratory distress and required invasive mechanical ventilation; a heamodynamic deterioration led to cardiac arrest and resuscitation measures failed.

The distinguishing features of this child was her immunosuppression and history of HSCT, she was also more profoundly lymphopenic and thrombocytopenic. All other laboratory values were variable between all three patients. Further information on her overall cardiorespiratory status pre-SARS-CoV-2 would be helpful to understand her vulnerabilities and to guide management of children presenting with similar comorbidities in the future.

Gine, CLopez, MJ Laparoendosc Adv Surg Tech A .Thoracoscopic Bullectomy for Persistent Air Leak in a 14-Year-Old Child With COVID-19 Bilateral Pulmonary Disease11 Jun 2020SpainEurope1Clinical - Comorbiditieshttps://www.liebertpub.com/doi/abs/10.1089/lap.2020.0289
Anurathapan, U.Hongeng, S.Bone Marrow Transplantation; www.nature.com/bmt/Hematopoietic stem cell transplantation from an infected SARS-CoV2 donor sibling11 Jun 2020ThailandAsia2Clinical - Comorbiditieshttps://www.nature.com/articles/s41409-020-0969-3
Du, HGao, YAllergyClinical characteristics of 182 pediatric COVID‐19 patients with different severities and allergic status10 Jun 2020ChinaAsia183Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/10.1111/all.14452
Sabatino, JDi Salvo, GJ Clin MedCOVID-19 and Congenital Heart Disease: Results from a Nationwide Survey8 Jun 2020ItalyEurope4Clinical - Comorbiditieshttps://www.mdpi.com/2077-0383/9/6/1774
Alloway, B. C.Hardy, G.Radiology Case reports Suspected case of COVID-19-associated pancreatitis in a child.6 Jun 2020USANorth America1Clinical - Comorbiditieshttps://reader.elsevier.com/reader/sd/pii/S1930043320302569?token=2F2186726A3F368F41FAC9F6CCCAB2CE9CB00D44308E9ADA898D0795CFDBF9CC12EE79807C3C0390C107B51CF81D49EA
Jones, B. A. Slater, B. J. Journal of Pediatric Surgery Case Reports Non-operative management of acute appendicitis in a pediatric patient with concomitant COVID-19 infection.6 Jun 2020USANorth America1Clinical - Comorbiditieshttps://reader.elsevier.com/reader/sd/pii/S1930043320302569?token=2F2186726A3F368F41FAC9F6CCCAB2CE9CB00D44308E9ADA898D0795CFDBF9CC12EE79807C3C0390C107B51CF81D49EA
Wahlster, LSankaran, VG Pediatr Blood CancerCOVID-19 presenting with autoimmune hemolytic anemia in the setting of underlying immune dysregulation.3 Jun 2020USANorth America1Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/full/10.1002/pbc.28382?af=R
Tennuri, UMiyatani, HClinics (Sao Paulo)Low Incidence of COVID-19 in Children and Adolescent Post-Liver Transplant at a Latin American Reference Center3 Jun 2020BrazilSouth America6Clinical - Comorbiditieshttps://www.scielo.br/pdf/clin/v75/1807-5932-clin-75-e1986.pdf
Mirzaree, SMMVossough, ARadiologyFocal Cerebral Arteriopathy in a COVID-19 Pediatric Patient 2 Jun 2020IranMiddle East1Clinical - Comorbiditieshttps://pubs.rsna.org/doi/pdf/10.1148/radiol.2020202197
Harman KGupta ALancetEthnicity and COVID-19 in children with comorbidities28 May 2020UKEurope12Clinical - Comorbidities https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30167-X/fulltext

Between 25 February 2020 and 28 April 2020, 12h children aged 0 to 16 years with confirmed COVID-19 who required admission to hospital were prospectively identified at Kings College Hospital London. 5 of these had known comorbidities (identified here as Group A) and 7 had no known comorbidities (Group B).

Age: Median age of Group A was 7.1yrs (range 0.2-15.3 with 2 <1 yr) and Group B was 4.8yrs (range 0-15.4).

Gender: 40% (n=2) in Group A and 71% (n=5) in Group B are male gender.

Ethnicity: 80% (n=4) in Group A and 71% (n=5) in Group B were from a black, Asian and minority ethnic (BAME) group.

Comorbidities: In Group A pre-existing comorbidities included cerebral palsy, prematurity, Wilsons disease, and dilated cardiomyopathy.

Clinical features: Most common symptoms on admission in group A and B respectively were fever (60%, n 3/5 and 86% n 6/7) and tachypnoea (60% n 3/5 and 71% n5/7). Liver dysfunction was observed in 4/5 patients in Group A but 2 had underlying liver conditions including one with Wilsons disease who has since had a liver transplant.

Radiology: In Group A radiological evidence of new infiltrates was seen in 50% (n2/4) of patients in Group A who had an x-ray because of clinical indication.

Bloods: In Group A 3 /5 patients had lymphopenia and thrombocytopenia, 3 /4 had raised CRP, 4/5 had liver dysfunction but 2 of these had underlying liver disease, 1/5 had renal dysfunction. None had symptoms that would be compatible with multisystem inflammatory syndrome. No blood data given for Group B.

Outcome: Median length of stay in hospital for Group A was 20 days (range 7-84 days) with 1child with liver transplant still an inpatient on 20th May 2020. For Group B the median stay was 3 days ( range 1-8 days); 1 admitted to hospital for safeguarding concerns and another was a neonate with vertical transmission of Covid-19.

Other salient feature: During this period 2288 adults were admitted to Kings College Hospital so children only formed 0.5% of total admissions. in Group A all children received antibiotics, 1 remdesivir and 1 hydroxychloroquine.

This case study presents data on 12 children with COVID-19 (5 of whom had comorbidities) admitted to Kings College Hospital London during 25th Feb-28th April 2020.

It is noteworthy that 75% of the total children admitted with Covid-19 and 80% of 5 children who had comorbidities were from a black, Asian, and minority (BAME) communities. Even keeping in mind that in Inner London 39% of the population is BAME, this data suggests that ethnicity in children may be an independent risk factor for severe disease. Conclusion is that Children from BAME communities particularly if they have comorbidities, may be at greater risk of severe disease from COVID-19. This is particularly significant given the ongoing investigation into the increased rates of severe COVID-19 infection in adults from BAME backgrounds.

This is a relatively new observation in children and although the numbers are very small, justifies considering this paper to be important.

Ferrari, ABalduzzi, APediatr Blood CancerChildren with cancer in the time of COVID-19: An 8-week report from the six pediatric onco-hematology centers in Lombardia, Italy26 May 2020ItalyEurope286Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/full/10.1002/pbc.28410

This Letter to the Editor describes the findings of 6 paediatric haematology and oncology centres in Lombardy during the 8 weeks after the COVID-19 pandemic began in Italy. Between 20th February 2020 and 15th April 2020 286 patients were tested for COVID-19 when accessing services at these centres: 74 were symptomatic, 25 had close contact with a diagnosed case and 187 were tested for screening purposes. Of these, 21 cases tested positive for COVID-19, with a median age of 6 years (range 1-17 years) and 48% were male.

Of the 21 cases 10 had leukaemia, 5 had soft tissue or bone sarcoma, 2 had lymphoma, two had hepatoblastoma, 1 had a CNS tumour and 1 had colon carcinoma. 15 patients were currently receiving treatment while 6 had completed treatment and were receiving follow up.

Clinical features: 1 patient (who had existing neurological respiratory impairment) developed aspiration pneumonia requiring respiratory support, and 1 developed atypical bilateral pneumonia with mild symptoms.

Outcomes: There were no deaths related to COVID-19 infection. Cancer treatment was modified in 10 cases (delaying chemotherapy, reducing drug doses and postponing surgery).

The authors observe that despite the overwhelming rate of COVID-19 in the general population in the region at the time, relatively few paediatric cancer patients were symptomatic, or tested positive for the virus, and that severe illness was rare. They suggest that these results may indicate that paediatric anti-cancer treatments could continue without major adjustments, especially as alterations may reduce their efficacy.

Of note, these centres experienced a reduction in newly diagnosed cancer cases to 55% of the expected rate, which may reflect delayed access to healthcare services.

Issitt, RWSebire, NJmedRxivCoronavirus (COVID-19) infection in children at a specialist centre: outcome and implications of underlying high-risk comorbidities in a paediatric population25 May 2020UKEurope166Clinical - Comorbiditieshttps://www.medrxiv.org/content/10.1101/2020.05.20.20107904v1

A retrospective cohort study published by Great Ormond Street Hospital (GOSH), London, UK suggested children who are defined as vulnerable in the COVID-19 pandemic era do not appear to be at significantly increased risk of being admitted to hospital with COVID-19. In addition, the vulnerable group have similar outcomes to those who are COVID-19 negative. However, the authors do identify children undergoing chemotherapy or radiotherapy are ‘over-represented’ in the vulnerable group. Data was collected from the institution’s electronic health record system. The inclusion criteria were any patient admitted between 01/03/2020 and 15/05/2020 who was admitted with features suggestive of COVID-19 based on the attending clinician’s interpretation, of undefined grade, including fever, cough and “systemic symptoms”. Children were defined as COVID-19 positive by a positive PCR test for nucleic acid in respiratory or blood specimens performed at the referring or presenting hospital or a documented positive familial test. Patients were classified as vulnerable if they fulfilled the high risk shielded list from NHS digital or the institutions local policy that was not provided. Due to the nature of the specialist paediatric services the population of children were highly selected.

166 children fulfilled the criteria; 65 (38.7%) were COVID positive and 101 (60.8%) were negative. The average age for COVID positive group was 9 years [IQR 0.9-14] with 38 (58.5%) males. This compared to the COVID-19 negative group with an average age of 1 year [0.1-5.75], 58 (55.4%) male. The COVID-19 positive patients were significantly older (p<0.001). Differences in ethnicity frequency was statistically significant for Asian ethnicity: 12 (8.5%) COVID-19 positive compared to 6 (5.9%) in the COVID-19 negative group (p=0.02).

The number of vulnerable children who were COVID-19 positive totalled 31 (47.7%) compared to 73 who were COVID-19 negative (72.3%), demonstrating a lower number of vulnerable children were positive for COVID-19, (p=0.002).

Clinical features: Breakdown of symptoms were not provided

Radiology: N/A

Bloods (For those COVID-19 positive):

ALT 41.5 U/L [IQR 29-74], Albumin 32 g/L [IQR 27-36], AntiDNAse 310U/mL [80.8-402], AntiStreptolysin O 285 IU/mL [134-384], AST 70 U/L [43-100], CRP 28 mg/L [10-74], CK 63.5 U/L [35-214], Creatinine 23 umol/L [14-46], D-dimer 1876 ug/L [1043-3618], Ferritin 788 ug/L [445-1863], Fibrinogen 3.65 g/L [2.4-4.8], Interleukin-6 50 pg/ml [50-152], Interleukin-10 50pg/mL, LDH 848 U/L [654-1136], BNP 3550 pg/ml [626-6992], Lymphocytes 1.44 X10^9/L [0.64-2.49], Neutrophils 3.90X10^9/L [1.46-8.6], WBC 8X10^9/L [3.38-13.2], Troponin I 54 ng/L [13-157], Prothrombin time 12 seconds [11.3-13], bilirubin 6 umol/L [3-10], Triglycerides 2.48 mmol/L [1.65-3.56].

The results highlight the difference in results between the COVID positive and negative groups but do not define further differences between vulnerable and non-vulnerable groups. These include a statistically higher average CRP (p=0.002, fibrinogen (p<0.001), albumin (p0.02) neutrophil (p<0.001) and white blood cell count (p<0.001) and a lower LDH (p=0.002),

Treatments: Patient were treated following national or speciality specific guidance. No further information was provided.

Outcomes: Mortality for those who were COVID-19 was 1 (1.5%) who was in the vulnerable group. Additional comments described the primary focus of treatment was aspiration pneumonia. This compared to 4 (4%) in the non-COVID-9 group, all of whom were in the vulnerable group. The difference in mortality rates was not statistically significant.

There was no difference in the proportion of vulnerable patients based on their COVID-19 status: 61% of vulnerable patients who were COVID-19 positive compared to 64.3% who were negative, (p = 0.84). Overall, comparing all patients, a significantly lower proportion of COVID-19 positive patients required mechanical ventilation (27.7%) than COVID-19 negative patients (57.4%), (p<0.001). The individual number of patients were not provided.

The average ICU length of stay for those with COVID-19 was 4 days [2.4-10.6]. For those in the vulnerable subgroup the average was 11 days [3.7-15.1]. The significance of the difference between the vulnerable and non-vulnerable group was not described. However, vulnerable non-COVID-19 patients had a 6 [2.8-12.2] day stay in ICU. The difference between vulnerable COVID-19 positive and negative groups demonstrated no significance (p=0.3).

The average total hospital stay for vulnerable patients with COVID-19 was 16.2 days [3.8-20.8]. This compared to vulnerable COVID-19 negative patient were in hospital for 12.3 days [5.2-19.8]. The difference in duration was not significant (p=0.94).

Other salient features: Breaking down conditions that comprises vulnerable children there was a significant increased number of children with cancer undergoing active chemotherapy or radiotherapy who were admitted to hospital with symptoms and COVID-19 positive status compared to with symptoms but COVID-19 negative [7 VS 3 (p=0.01)]. There was no statistical differences between the COVID-19 positive and negative categories with on the national transplant, transplant medication, haematological cancer, respiratory and rare genetic, metabolic and autoimmune conditions lists or local severe respiratory conditions, rare diseases immunosuppressive therapies and other potential factors lists.

Barsoum, ZSN Comprehensive Clinical MedicinePediatric Asthma & Coronavirus (COVID-19)-Clinical Presentation in an Asthmatic Child—Case Report19 May 2020Northern IrelandEurope1Clinical - Comorbiditieshttps://link.springer.com/content/pdf/10.1007/s42399-020-00310-3.pdf
Hains, DKrammer, FJAMAAsymptomatic Seroconversion of Immunoglobulins to SARS-CoV-2 in a Pediatric Dialysis Unit14 May 2020USANorth America3Clinical - Comorbiditieshttps://jamanetwork.com/journals/jama/fullarticle/2766215
Boulad, FBouvier, NJAMA Oncol.COVID-19 in Children With Cancer in New York City13 May 2020USNorth America20Clinical - Comorbiditieshttps://jamanetwork.com/journals/jamaoncology/fullarticle/2766112

This research letter reports the results of SARS-CoV-2 screening of patients and caregivers from one of the largest paediatric cancer centres in the US (Memorial Sloan Kettering Cancer Center, New York) in a region with very high levels of community SARS-CoV-2 transmission.

From March 10th to April 12th 2020, inpatients and outpatients with either symptoms of or exposure to SARS-CoV-2 infection underwent RT-PCR testing. Asymptomatic patients were also tested prior to admission, deep sedation and or myelosuppressive chemotherapy, as were caregivers of children being admitted.

Overall 11% (20/178) of paediatric patients returned a positive SARS-CoV-2 result; including 29.3% in the symptomatic / exposed group and 2.5% in the asymptomatic group. In contrast 14.7% (10/76) of asymptomatic caregivers were positive. Despite close contact, 5 of the 10 children of caregivers with SARS-CoV-2 were uninfected.Only 1 of the 20 paediatric patients required hospitalisation for COVID-19 symptoms, without need for critical care.

This data provides reassurance that children with cancer may not be more vulnerable to complications of SARS-CoV-2 infection compared to other children. The lack of specific clinical detail in this report limits the ability to draw more definitive conclusions regarding risk.

The lower rate of asymptomatic carriage in children relative to their caregivers provides further evidence that children, including paediatric cancer patients, may be less susceptible to SARS-CoV-2 infection compared with adults.Clearly infection control strategies must consider the risk of nosocomial spread from infected caregivers as well as paediatric patients, particularly in areas with high levels of community transmission.

Marlais, MTullus KLancet Child Adolesc HealthThe severity of COVID-19 in children on immunosuppressive medication13 May 2020Multi-countryMulti-region18Clinical - Comorbiditieshttps://www.thelancet.com/pdfs/journals/lanchi/PIIS2352-4642(20)30145-0.pdf
Bush, R.Upadhyay, K.Am J TransplantMild COVID-19 in a Pediatric Renal Transplant Recipient13 May 2020USANorth America1Clinical - Comorbiditieshttps://pubmed.ncbi.nlm.nih.gov/32406181/
Zhao, YGao, GPediatr Infect Dis JFIRST CASE OF CORONAVIRUS DISEASE 2019 IN CHILDHOOD LEUKEMIA IN CHINA12 May 2020ChinaAsia1Clinical - Comorbiditieshttps://journals.lww.com/pidj/Abstract/9000/FIRST_CASE_OF_CORONAVIRUS_DISEASE_2019_IN.96166.aspx
Angelletti, AForno, RClin TransplantRisk of COVID-19 in young kidney transplant recipients. Results from a single-center observational study12 May 2020ItalyEurope64Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/abs/10.1111/ctr.13889

Giannina Gaslini Children’s Hospital, Italy undertook this prospective observational study of patients, who received a kidney transplant between January 2010 and March 2020, with stable graft function and were taking chronic immunosuppressant therapy. They were interviewed weekly between 24th February and 12th April 2020 for 7 weeks, using a 12-point structure questionnaire contained in the appendix, to evaluate the health status of themselves and their cohabitants. The data for adults and children were combined presenting a median age of 20 (2-30) years. The demographics were reported as a combined total; 93 were male.

2 patients, an adult (information not included) and 1 girl aged 13, had co-habitants who were positive for SARS-CoV-2. The 13-year-old had a kidney transplant aged 9 years old. At the time of study, she was taking a combination of steroid, calcineurin inhibitor (CNI and mycophenolate mofetil (MMF) and had investigations including a white cell count and haemoglobin within normal limits.

She tested negative for SARS-CoV-2 using a nasopharyngeal swab (test not declared) and did not develop any symptoms in the subsequent 21 days, declared as the incubation period. Anti-SARS-CoV-2 antibodies were also negative at an undefined time point.

Clinical features: No patients developed any clinical symptoms.

Radiology: None discussed.

Bloods: None discussed for patients who were positive for SARS-CoV-2.

Treatments: None.

Outcomes: None.

Other salient features: The authors recommend avoiding altering the immunosuppressive therapy in young transplant recipients who do not have symptoms of SARS-CoV-2 including those who are exposed to positive close contact. Despite observing a relatively large population of kidney transplant recipients, a small number, 2 (1 child) were exposed to SARS-CoV-2, upon which has the conclusions are based.

Koczulla, RAKneidinger, NAmerican Journal of TransplantationSARS-CoV-2 infection in two patients following recent lung transplantation12 May 2020GermanyEurope1Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/abs/10.1111/ajt.15998
Blanchon, SRochat, IPediatr PulmonolCOVID-19: A Message of Hope From a Young Girl With Severe Cystic Fibrosis11 May 2020SwitzerlandEurope1Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/epdf/10.1002/ppul.24812
Brenner, EUngaro RGastroenterologyCorticosteroids but not TNF Antagonists are Associated with Adverse COVID-19 Outcomes in Pateitns with Inflammatory Bowel Disease: Results from an International Registry. 8 May 2020USANorth America30Clinical - Comorbidities https://www.sciencedirect.com/science/article/pii/S0016508520306557

This is a pre-proof article and therefore has not yet undergone final editing and review.This is an article from America (Carolina) aiming to characterise the clinical course of COVID-19 on patients with inflammatory bowel disease (IBD) and evaluate the association between demographics, clinical characteristics and immunosuppressant treatments of COVID-19 outcomes.

The authors created a surveillance database and healthcare providers were encouraged to voluntarily report all cases of Polymerase Chain Reaction (PCR)-confirmed COVID-19 patients with IBD. A website was developed to enable international contributions. Contributors were asked to report cases a minimum of 7 days from symptom onset and after sufficient time had passed to observe disease course through to resolution of acute illness or death.

525 patients from 33 countries were reported. 7% had severe COVID-19, 31% were hospitalised, 3% of patients died. The median age of patient was 41 years (from 5 to 90). The majority of patients had Crohns Disease (59.4%) and IBD disease activity was classed as remission in 58.9% of cases. The most common class of treatment was TNF antagonist therapy (43.4% of patients).

63.5% of patients had no comorbidities other than IBD. Most patients who died had other co-morbidities. Only 3 paediatric patients (10% of paediatric cases) required hospitalization. After controlling for all other covariates use of systemic corticosteroids and ASA/sulfasalazine use were strongly associated with more serious outcomes after infection with COVID-19 but there was no significant association seen between TNF antagonist use and adverse outcomes.

The authors observed an age-standardized mortality ration of approximately 1.5-1.9 as compared to the general populations of China, Italy and the U.S.

They state it is reassuring that the most commonly used treatment- TNF antagonists- appears not to lead to increased adverse outcome for patients infected with COVID-19.

This study has strength in that it includes data from many countries although how comparable that data can be between countries is debatable. The authors did not look at dosing regimens or what was done in terms of continuing or postponing treatment which may well have varied from one country to another. There may also be some bias towards patients who were unwell enough to present to hospital, there may have been other patients who were infected but not unwell enough to require hospital treatment/testing for COVID-19 who would not have been included in this study population.

de Rojas, TPerez-Martinez, APediatric Blood and CancerCOVID-19 Infection in children and adolescents with cancer in Madrid8 May 2020Italy Europe15Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/full/10.1002/pbc.28397
Andre, NGandemer, VPediatr Blood CancerCOVID-19 in pediatric oncology from French pediatric oncology and hematology centers: High risk of severe forms?8 May 2020FranceEurope33Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/full/10.1002/pbc.28392
Morand, AFabre AArchives de PediatrieChild with liver transplant recovers from COVID-19 infection. A case report. 6 May 2020franceEurope1Clinical - Comorbidities https://www.sciencedirect.com/science/article/pii/S0929693X2030110X

This a case report form France of a 2-and-a-half-year-old girl who recovered from COVID-19 infection, 5 months after a liver transplant; she had co-infection with Epstein-Barr virus (EBV).

The child had received a living donor transplant (father) as she had developed portal hypertension post Kasai portoentemrostoy performed at 53 days of age for biliary atresia.

She had been discharged home 20 days post procedure on tacrolimus immunosuppression therapy and had no immunization against EBV before transplantation.

On day 96 post transplant she was found to have primary EBV infection linked to the transplant- her father was EBV positive- but was asymptomatic of this.

The first developed rhinitis which developed into a fever, cough and tachypnoea. In the few days before this her mother had been hospitalized with pneumonia and found to be COVID-19 positive on nasopharyngeal swab. On day three of the illness the child was referred to hospital where she was found to be positive for COVID-19 on NPA.

On admission she was tachypnoeic with no other signs of respiratory distress, her CRP was low (3). A chest CT showed focal alveolar condensation of the ligula and a stable mediastinal enlargement. Her liver function tests had deteriorated (GGT and AST). An US of the liver showed aggravation of the transplanted biliary tract stenosis and an elevated EBV blood viral load. She was managed symptomatically, and she did not receive any COVID-19 specific treatment.

She recovered from COVID-19 infection despite the high level of immunosuppression caused by her tacrolimus treatment. NPA test samples became negative on day 11. The authors report they reduced the dose of tacrolimus but do not state at which point in the illness nor for how long. They do not state how long it took for her LFTs to return to previous levels nor if there were any consequences of the raised EBV viral load.

The authors suggest liver transplantation is not associated with COVID-19 symptom severity development even when there is high level immunosuppression on tacrolimus. Moreover COVID-19 and EBV co-infections do not seem to aggravate the clinical outcome.

It is difficult to draw conclusions based on one case study. Particularly as other studies have shown the severity of COVID-19 is increased when present with other co-morbidities. This particular patient, due to the nature of her original liver insult and the fact that she is a young patient, did not have other co-morbidities, this is often not the case for other patients who have required a liver transplantation.

Michelena, XMarsal, S.Med archivesIncidence of COVID-19 in a cohort of adult and paediatric patients with rheumatic diseases treated with targeted biologic and synthetic disease-modifying anti-rheumatic drugs5 May 2020SpainEuropeClinical - Comorbiditieshttps://www.medrxiv.org/content/10.1101/2020.04.30.20086090v1.full.pdf
Sieni, EFavre, CBritish Journal of HaematologyFavourable outcome of Coronavirus‐19 in a 1‐year‐old girl with acute myeloid leukaemia and severe treatment‐induced immunosuppression5 May 2020ItalyEurope1Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/epdf/10.1111/bjh.16781

This retrospective single case report discusses the progression and treatment of a child with high risk acute myeloid leukaemia having undertaken the third chemotherapy cycle of the induction phase following AIEOP LAM 2013 protocol.

13-month-old female patient attended routine clinic at Myers Hospital, Florence, Italy following completion of the chemotherapy. Routine investigations revealed a low white cell count, haemoglobin and platelet count which necessitated admission for transfusions. The need for admission was the initial reason for testing for SARS-CoV-2. RT-PCR was performed for nasal and pharyngeal swabs. Faecal PCR testing was also positive.

Clinical features: Fever starting on day 3 (the combination of fever and low WCC suggested neutropenic sepsis), vomiting and diarrhoea with negative stool culture.

Radiology: CXR on day 3 showed bilateral reticular markings. A repeat prior to discharge demonstrated “no significant modification from baseline”.

Bloods: Day 0 showed low WCC (80/mmc), haemoglobin (7.9g/dL) and platelet (5000/mmc) count. The elevated CRP was highest at day 5 (7.2mg/dL) and normalised by day 10 (<0.5mg/dL). Additional laboratory investigations included LDH which was highest by day 13 (401 IU/L) and ferratin maximally raised on day 9 (3000 mg/mL). Immunoglobulins were low throughout the illness. On day 3 the results were: IgG 258 mg/dL, IgA 18.7 mg/dL, IgM 7 mg/dL. IL-1β, IL-6, IL-10, TNFα and cardiac enzymes were normal.

Blood microbiology was negative.

Additional laboratory investigations, including cytokines (IL-1β, IL-6, IL-10 and TNFα) and cardiac enzymes, were normal; lactate dehydrogenase slightly increased (up to 401 IU/L at day 13), whereas ferritin values showed moderate elevation from day 9

Treatments: Treatment for neutropenic sepsis with piperacillin-tazobactam and fluconazole was commenced on day 3 due to fever. Hydroxychloroquine day 3-11. On day 4 lopinavir/ritonavir stopping day 12

Outcomes: Was treated on a hospital ward without supplemental oxygen until discharge.

Other features of interest: There was a undetectable viral plasma load by day 16, however nasal swab for SARS-CoV-2 remained positive beyond discharge at day 26. There is no data to suggest a negative test to publication date.

It is unclear if the low WCC, anaemia and thrombocytopenia requiring transfusion was due to the chemotherapy, underlying acute myeloid leukaemia or COVID-19 infection, however, on discharge these values had normalised and were maintained by day 26.

Summary: This case describes a high-risk young patient with acute myeloid leukaemia undergoing chemotherapy presenting with febrile neutropenia. Whilst the symptoms were initially vague, subsequent investigations suggested the underlying cause was SARS-CoV-2. Early anti-viral treatments were commenced. Given the patient’s immunosuppression the authors discuss fears regarding seroconversion, viral dissemination and inflammatory responses which did not occur.

Melgosa, MPerez-Beltran, VPed NephrolSARS-CoV-2 infection in Spanish children with chronic kidney pathologies1 May 2020Spain Europe16Clinical - Comorbiditieshttps://link.springer.com/content/pdf/10.1007/s00467-020-04597-1.pdf
Odièvre, MCorvol, HAm J HematologyDramatic improvement after Tocilizumab of a severe COVID-19 in a child with sickle cell disease and acute chest syndrome1 May 2020FranceEurope1Clinical - Comorbiditieshttps://onlinelibrary.wiley.com/doi/10.1002/ajh.25855

The authors of this case study are based at two hospitals in Paris; in this correspondence they describe the treatment of a 16 year old girl with homozygous sickle cell disease (SCD) admitted to ICU with acute chest syndrome (ACS) and pulmonary emboli complicating COVID-19 pneumonia, in particular the use of Tocilizumab, a humanised anti-IL-6 monoclonal antibody (usual indications include use as immunosuppressant therapy in rheumatoid arthritis and giant cell arteritis in adults and juvenile idiopathic arthritis in children).

Course of SCD prior to admission: The patient had a history of recurrent vaso-occlusive crises and abnormal transcranial dopplers between the ages of 5 and 11 years old, necessitating treatment with exchange transfusions. At 11 years of age she was commenced on daily hydroxyurea with resolution of vaso-occlusive events. She had no history of ACS or pulmonary hypertension; respiratory function and chest radiography were previously normal.

Presentation with COVID-19-19: She presented with isolated fever, with nasophyaryngeal swabs subsequently confirmed as RT-PCR SARS-CoV-2 positive. 7 days later she developed acute chest pain associated with respiratory distress (SpO2 85%).

Radiology: CT pulmonary angiogram (CTPA) showed bilateral pulmonary emboli and bilateral consolidation with right-sided halo sign.

Treatment in ICU: Included non-invasive ventilation, anticoagulation and red cell exchange transfusion followed by simple transfusion (lowest Hb 64 g/L). Based on recent experience in adult SCD patients with COVID-19 disease she also received a single infusion of Tocilizumab (8 mg/kg). The authors report rapid clinical improvement after Tocilizumab with repeat CTPA 5 days later showing complete resolution of pulmonary emboli and consolidation on the right and decrease on the left. She was discharged from hospital 11 days after admission to continue oral anticoagulation for 6 weeks.

Conclusions: Inflammatory cytokines such as IL-6 and TNF- are elevated in COVID-19. COVID-19 pneumonia can cause ACS in SCD patients; there have been several recent reports of successful treatment using Tocilizumab.

Inci Yildirim, ATurkmen Karaagac, AIndian PediatricsCOVID-19 in a Young Girl with Restrictive Cardiomyopathy and Chronic Lung Disease30 Apr 2020TurkeyWestern Asia, Southeastern Europe1Clinical - Comorbiditieshttps://www.indianpediatrics.net/june2020/577.pdf
Russell M.Reardon LThe Journal of Heart and Lung TransplantationCOVID-19 in a paediatric heart transplant recipient: Emergence of donor-specific antibodies 29 Apr 2020UKEurope1Clinical - Comorbidities https://www.jhltonline.org/article/S1053-2498(20)31532-1/fulltext

This is a case report of a 3 year old child who had received a heart transplant at 11 months of age for congenital dilated cardiomyopathy.

Her post-transplant course had been unremarkable except for persistent Ebstein Barr Virus (EBV) viremia. She was on tacrolimus monotherapy.

Her initial symptoms were productive cough with rhinorrhea and nasal congestion, she was not tested for COVID-19 at this point as she had no Centres for Disease Control risk factors for infection and testing was not widely available.

A week later a follow-up telehealth visit was performed and there was improvement in symptoms.Surveillance blood tests demonstrated the following de novo Class II donor specific antibodies: DQ4, DR8 and DQA1*04.

One week later the patient was scheduled for routine admission for intravenous immunoglobulin administration, because of the history of cough had a nasal swab sent for reverse transcriptase polymerase chain reaction testing for COVID-19. Other than an intermittent wet cough she was well, and her observations were within normal limits. She received the immunoglobulin infusion overnight. The next morning the nasal swab was reported as positive for COVID-19 infection.

The patient remained well without symptoms of respiratory distress. Repeat COVID-19 nasal polymerase chain reaction testing was planned for 2 weeks with IVIG administration repeated every month for 2 more months. The authors report that although the patient tolerated IVIG administration with concurrent COVID-19 infection without any notable reaction they would be hesitant to attempt more aggressive forms of desensitisation with active infection until more clinical knowledge of COVID-19 is available.

Climent, F. J.Pérez-Martínez, ARev Esp Cardiol (Engl Ed). Fatal outcome of COVID-19 disease in a 5-month infant with comorbidities27 Apr 2020SpainEurope12Clinical - Comorbiditieshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183979/pdf/main.pdf
Schwierzeck, VKampmeier, SClin Infect DisFirst reported nosocomial outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a pediatric dialysis unit27 Apr 2020GermanyEurope13Clinical - Comorbiditieshttps://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa491/5825509

This paper presents the results of an outbreak investigation following a member of staff on a paediatric dialysis unit developing confirmed COVID-19. Detailed contact tracing was carried out and found that 48 cases in total were involved - this included 13 patients, 28 healthcare workers and seven 'accompanying persons'. Of note, of the 3 traced who children tested positive for SARS-CoV-2, only one had symptoms; given these children's high-risk status, their asymptomatic presentations are noteable. The paper discusses hygiene measures put in place to avoid further spread.

Chen, YHuang, KDiabetes CareClinical Characteristics and Outcomes of Patients With Diabetes and COVID-19 in Association With Glucose-Lowering Medication24 Apr 2020ChinaAsia3Clinical - Comorbiditieshttps://care.diabetesjournals.org/content/early/2020/05/13/dc20-0660
Poli, PBadolato, RJ. Cyst FibrosAsymptomatic case of COVID-19 in an infant with cystic fibrosis14 Apr 2020ItalyEurope1Clinical - Comorbiditieshttps://www.cysticfibrosisjournal.com/article/S1569-1993(20)30096-5/fulltext#%20

This is the first case report of confirmed SARS-CoV-2 infection in a child with cystic fibrosis. The 1 month-old, from Italy, was diagnosed with CF on newborn screening. SARS-CoV-2 infection was confirmed on nasopharyngeal swab PCR as part of contact tracing following exposure to COVID-19 through his grandfather.

The infant remained asymptomatic throughout follow up and did not require hospital admission.This is one of a limited number of reports of SARS-CoV-2 infection in people with CF. A better understanding of the course of illness in this group will likely emerge with data from ongoing collaborative studies.

Hrusak, OSchrappe, MEur J CancerFlash survey on SARS-CoV-2 infections in pediatric patients on anti-cancer treatment7 Apr 2020International (first author from Czechia)International9Clinical - Comorbiditieshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141482/

This is the report of a data from an international survey of paediatric haematology and oncology clinicians to assess the frequency and severity of SARS-CoV-2 infection amongst children with cancer. The survey, conducted from 16th-17th March 2020, had over 35 respondents from 25 countries. Of an estimated 10,000 patients at risk and over 200 tested, 9 children were positive for SARS-CoV-2. Clinical details are provided for 8 cases, 6 of whom had solid tumours and 2 with acute lymphoblastic leukaemia. 7 had mild or asymptomatic disease, 1 patient required low flow oxygen. Fever was the presenting symptom in 6 patients and one patient also had diarrhoea. All 7 patients with outcome data available made a full recovery.

The interpretation of these data is clearly limited by the study design as well as the relatively early stage of the pandemic during which the survey was conducted. Notwithstanding these limitations, the absence of severe COVID-19 cases in this report provides some early reassurance. More detailed clinical studies are needed to draw firm conclusions about the risk of severe disease in children receiving chemotherapy.

Balduzzi, ABiondi, ALancet pre-print serverLessons after the early management of the COVID-19 outbreak in a pediatric transplant and hemato-oncology center embedded within a COVID-19 dedicated hospital in Lombardia, Italy2 Apr 2020ItalyEurope5Clinical - Comorbiditieshttps://dx.doi.org/10.2139/ssrn.3559560

This report from a paediatric haematology unit in Lombardia, Italy, includes the Italian experience of COVID-19 in children with malignancy so far. At their particular unit, they have had no children with malignancy test positive for COVID-19 (they admit this is dependent on testing criteria, requiring hospitalisation at their institute). They are aware of 5 cases of paediatric cancer patients who have had COVID-19 and have all suffered a mild course, with 3 managed at home and 2 in hospital.

This small case series provides further reassurance for at risk paediatric populations.

Lagana, SMLefkowitch, JHArchives of Pathology & Laboratory MedicineCOVID-19 associated hepatitis complicating recent living donor liver transplantation2 Apr 2020USANorth America1Clinical - Comorbiditieshttps://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2020-0186-SA

This retrospective single case report examines the histopathological features of liver associated COVID-19 in a child admitted to Columbia University Medical Centre, USA. The female child, 6 months old, was admitted for a liver transplant for treatment of biliary atresia. COVID-19 was diagnosed in the donor on post-operative day 2 and confirmed in the patient day 4 post-operatively. The type of test used was not described.

Clinical features: Increased work of breathing requiring CPAP, fever and diarrhoea were developed on post-operative day 4.

Radiology: CXR on post-operative day 4 was described as “no significant changes compared to prior exam with only patchy areas of atelectasis in irregularly aerated lungs”. CXR on day 6 demonstrated “patchy lung opacities bilaterally, mildly increased in the right upper lobe and left lung base”. Bloods: Deranged LFTs exacerbated from baseline on post-operative day 1: AST (maximum 908U/L from 163U/L), ALT (maximum 980U/L from 215U/L), GGT (maximum 473U/L from 174U/L), ALP (maximum 578U/L from 388U/L).

Treatments: Treated with hydroxychloroquine from day 4 post-operative. She required CPAP for an undefined time period. Undefined immunosuppressant treatment was provided for acute transplant rejection, however liver enzymes worsened when commenced.

Outcomes: Remains on a hospital ward without supplemental oxygen.

A liver biopsy was performed on post-operative day 7 demonstrating portal tract expansion through a mixed inflammatory infiltrate which consisted of lymphocytes, rare plasma cells, and interspersed eosinophils, lymphocytic cholangitis, reactive changes in the interlobular bile ducts and mild portal venulitis. These were interpreted as acute cellular rejection.

Other findings of moderate acute hepatitis including an “azonal pattern of clusters of apoptotic hepatocytes” and singly dispersed apoptotic hepatocytes. Other features of interest include large fragments of cytoplasmic debris described as “crumbling” hepatocytes, few mitotic figures, regions of Kupffer cell prominence with sinusoidal and central vein endotheliitis. The authors commented that the extent of hepatocyte apoptosis and large clusters were unusual and not a usual feature of acute cellular rejection (ACR). Central endotheliitis may also be a feature of COVID-19 hepatitis, with the presence of more Kupffer cells and less plasma cells than ACR.

Summary: COVID-19 hepatitis likely presents as a moderate acute hepatitis with prominent clusters of “crumbling” apoptotic hepatocytes. Other features may be lymphohistiocytic inflammation of sinusoidal and central vein endothelium, with the presence of more Kupffer and less plasma cells when compared to ACR.

Turner, DRussel, RJournal of Pediatric Gastroenterology and NutritionCOVID-19 and paediatric inflammatory bowel diseases31 Mar 2020InternationalInternational8Clinical - Comorbiditieshttps://doi.org/10.1097/MPG.0000000000002729

This article outlines the experience from Asia and Europe so far of children with inflammatory bowel disease given the COVID-19 pandemic. This is of particular interest because many of these children receive immunosuppression as part of their treatment, and so could be considered high risk for complications of the disease.

It appears to have been routine practice to suspend treatment for IBD during the outbreak of COVID-19, which resulted in a large number of relapses. No children with IBD contracted COVID-19 in China in the period covered by the survey.

In South Korea treatment for IBD was not suspended. They also have had no cases of COVID-19 in children with IBD.

In the PORTO IBD group of ESPGHAN (covering Europe, some centres in Canada and Israel) treatment was not suspended in 31/32 centres. 7 children with IBD, who were on immunosuppression, had COVID-19. They all suffered a mild illness with no flare of their IBD. There is an additional child case from an international IBD database identified who also experiences mild symptoms (no hospitalisation required).

This survey provides further reassurance that treatment with immunosuppression does not appear to significantly increase the risk of severe disease from COVID-19 in children.

D'Antiga, LLiver transplantationCoronaviruses and immunosuppressed patients: the facts during the third epidemic20 Mar 2020ItalyEurope3Clinical - Comorbiditieshttps://doi.org/10.1002/lt.25756

This letter is from a liver transplant centre in Lombardy, Italy, reporting their experience of patients (including children) with immunosuppression and COVID-19. They have had 3 children post liver transplant test positive for SARS-CoV-2, and none have developed clinical pulmonary disease. They believe due to the widespread nature of infection that many other of their patients may also be infected, but not developed clinically apparent disease.

This provides the first official reports of vulnerable paediatric populations with COVID-19, which so far does not appear to be any more severe than the rest of the population in that age bracket. Further data is awaited.

Godfred-Cato, SBelay, EMorb Mortal Wkly Rep COVID-19–Associated Multisystem Inflammatory Syndrome in Children — United States, March–July 20207 Aug 2020United StatesNorth America570Clinical - PIMS-TShttps://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932e2-H.pdf

On May 14th 2020, the CDC (Centre of Disease Dontrol) In the United states issued an alert on Multisystem Inflammatory Syndrome in Children, and asked clinicians to report any suspected cases to local and state health departments.

As of 29 July 2020, a total of 570 MIS-C patients with onset dates from March 2 to July 18, 2020, had been reported from 40 state health departments, the District of Columbia, and New York City. The median patient age was 8 years (range = 2 weeks–20 years); 55.4% were male, 40.5% were Hispanic or Latino (Hispanic), 33.1% were non-Hispanic black (black), and 13.2% non-Hispanic white (white). Obesity was the most commonly reported underlying medical condition, occurring in 30.5% of Hispanic, 27.5% of black, and 6.6% of white MIS-C patients. 364 (63.9%) of patients needed ICU care, and 10 children (1.8%) died.

Latent class analysis (LCA), a statistical modelling technique that can divide cases into groups by underlying similarities, was used to identify and describe differing manifestations in patients who met the MIS-C case definition. Indicator variables used in the analysis were presence or absence of SARS-CoV-2–positive test results by PCR or serology, shock, pneumonia, and involvement of organ systems.

This analysis divided the cohort of patients into three groups.

Class 1: 203 (35.6%) patients. Median age 9 years. These patients had the highest number of involved organ systems. Of this group, 99 (48.8%) had involvement of six or more organ systems; most commonly cardiovascular (100.0%) and gastrointestinal (97.5%). Compared with other Classes they had significantly more shock/abdominal pain/myocarditis/lymphopenia and markedly raised inflammatory markers. Coronary artery dilatation and aneurysm rate was 21.1%. 10 (4.9%) met full criteria for Kawasaki disease. 98% had positive Sars COV2 positive serology with/without positive PCR. 1 child from this group died (case fatality rate 0.5%)

Class 2: 169 (29.6%) patients. Median age 10 years. In this group, 129 (76.3%) had respiratory system involvement. These patients were significantly more likely to have cough, shortness, ARDS. Coronary artery dilatation and aneurysm rate 15.8%. 5 children (3%) met full criteria for Kawasaki disease. Most of this group (84%) had Sars CoV2 positive PCR without positive serology. This suggested Class 2 had severe acute Covid 19 disease. Nine children in this group died, giving the highest case fatality 5.8%

Class 3: 198 (34.7%) patients. Median age 6 years (significantly younger). This group had the highest prevalence of rash (62.6%), and mucocutaneous lesions (44.9%). Prevalence of coronary artery aneurysm and dilatations was 18.2%. 6.6% met criteria for complete Kawasaki disease. This group had the lowest prevalence of underlying medical conditions, organ system involvement, complications (e.g., shock, myocarditis), and markers of inflammation and cardiac damage. 63.1% had positive SARS-CoV-2 serology only and 33.8% had both serologic confirmation and positive RT-PCR results. None of these children died.

Comparison with UK report of PIMS-TS;The association of Covid 19 with an inflammatory syndrome has been reported in many countries across Europe following on from the peak outbreaks in the respective countries. In the UK, Whittaker et al, in JAMA in June, published a cohort of 58 children who met the criteria for PIMS-TS. These 58 children were reported as one group; however they were stratified by shock, Kawasaki disease, Kawasaki clinical criteria, coronary artery aneurysm, and prevalence of Sars CoV 2 infection (PCR or serology). Though direct comparison across the groups is somewhat difficult, some similarities and differences are apparent.

CDC Class 1 with shock abdominal pain and a somewhat older age group at presentation, with markedly raised inflammatory markers, is seen also in the UK group. The prevalence of abdominal symptoms is significantly higher in those where KD disease or clinical criteria is not met.

Similarly CDC Class 3 group of younger children with increase prevalence of mucocutaneous lesions, and rash were younger, and lower prevalence of shock is seen in the UK cohort when stratified.

CDC Class 2 with 76.3% respiratory involvement is not really reflected in the UK cohort, with respiratory symptoms only present in 26% of the total group, without wide variation when the UK group is stratified. It appears that this CDC Class 2 may be representative of acute severe Covid infection, which was not incorporated UK PIMS-TS cohort.

Coronary artery dilation and aneurysm was higher across all CDC classes compared with UK cohort prevalence of 14%.

Jhaveri SStern KJpeds Longitudinal Echocardiographic Assessment of Coronary Arteries and Left Ventricular Function Following Multisystem Inflammatory Syndrome in Children (MIS-C)2 Aug 2020United StatesNorth America15Clinical - PIMS-TShttps://www.jpeds.com/article/S0022-3476(20)30984-7/pdf
Diorio, CBassiri, HJCIMultisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS-CoV-230 Jul 2020USANorth America20Clinical - PIMS-TShttps://www.jci.org/articles/view/140970#sd

According to the authors this is a prospective report comparing life threatening complications of SARS-CoV-2 in children.

Children admitted to the Children's hospital of Philadelphia between April 3rd and May 15th 2020 were prospectively screened and enrolled if there was evidence of past or present SARS-CoV-2 infection. After enrolment the children were categorised by clinical presentation as MIS-C, severe COVID-19 or minimal COVID-19.

Data collected included demographics, co-morbid conditions, sources of co-infection, treatments used and many laboratory investigations particularly looking for organ dysfunction and inflammatory markers.

26 children were enrolled, there was only sufficient data on 20. Of these 6 met the criteria for MIS-C (and 2 of these also met criteria for Kawasaki Disease), 9 severe COVID-19 and 5 minimal COVID-19. All 6 MIS-C patients had been previously healthy and were younger than the other groups. 8 of the 9 severe COVID-19 had pre-existing conditions and all 5 of the minimal COVID-19 had other infections or pre-existing conditions which were the reason for admission. Ethnicity showed no significant differences between the groups. Among the wealth of analyses, only TNF+IL-10 significantly distinguished between MIS-C and severe COVID-19 (p=0.036). Data also supports an infective aetiology for MIS-C.

This is a small study from early in the pandemic (enrolment was started before CDC alert on MIS-C in USA). Various hypotheses are mentioned but not statistically proven. The authors themselves state "We believe these results can inform hypotheses for future studies when larger cohorts are available and we would caution against broad generalisation of these results until such work is complete.

Lee, PYSon, MBFJ Clin Invest 2020Distinct clinical and immunological features of SARS-COV-2- induced multisystem inflammatory syndrome in children23 Jul 2020USANorth America28Clinical - PIMS-TShttps://www.jci.org/articles/view/141113

28 children with MIS-C and evidence of SARS-CoV-2 were identified at a tertiary referral unit in Boston, USA, between March and June 2020. Age range, 1 month–17 years; median, 9 years. 57% male. Statistically significant over-representation of black and Hispanic cases. 50% had pre-existing medical conditions. Comprehensive data is given on the clinical and immunological features, treatment and outcomes.

The pattern of MIS-C showed a clear distinction from both Kawasaki disease and Macrophage Activation Syndrome. Respiratory features were mild compared to adult MIS (none mechanically ventilated, 25% non-invasive support, 14% supplemental O2 only) but other organ systems were similarly affected (GI 54%, conjunctivitis 57%, rash 36%, low platelets 64%, low lymphocytes 75%, raised D-dimers 96%, acute kidney injury 21%, L ventricular dysfunction 39%). 61% required ICU admission, 54% due to hypotension/shock, but none developed ARDS. Intravenous immunoglobulin (71%), corticosteroids (61%), remdesivir (25%), anakrina (18%) and hydroxychloroquine (1 case) were given as immunomodulatory treatments, with clinical improvement in all cases. There were no deaths.

To, KKwan, MDiagnostic Microbiology and Infectious DiseaseFalse-positive SARS-CoV-2 serology in 3 children with Kawasaki disease17 Jul 2020ChinaAsia3Clinical - PIMS-TShttps://doi.org/10.1016/j.diagmicrobio.2020.115141

This retrospective case study of three children with typical Kawasaki disease reports the discrepancy between positive tests for SARS-CoV-2 anti-NP or anti-RBD IgG, and subsequent microneutralization assays which were negative in all three.

Clinical features: The study took place in Hong Kong, China. Three children were identified as having typical Kawasaki disease between January and April 2020. Two were aged 3 months and one was aged 6 months; two were girls and one a boy. None reported any epidemiological links to individuals with COVID-19 or any travel history in areas with COVID-19 outbreaks.

All three had fever, conjunctivitis, a maculopapular rash, cracked or erythematous lips and rhinorrhea. Two had in addition a cough and one had cervical lymphadenopathy. Two had abnormal echocardiograms (perivascular echogenicity and non-tapering coronary arteries) and one had a normal echocardiogram.

Each patient tested negative for SARS-CoV-2 and other common respiratory pathogens in nasopharyngeal aspirate polymerase chain reaction (PCR).

Bloods: One patient tested positive for SARS-CoV-2 anti-RBD and anti-NP IgG after 60 days; a second patient tested positive for SARS-CoV-2 anti-RBD and anti-NP IgG after 87 days; and the third patient tested positive for only SARS-CoV-2 anti-RBD IgG after 90 days.

All three patients subsequently tested negative for SARS-CoV-2 neutralising antibodies by microneutralization assay (a titre ≥10 was considered positive).

Outcomes: All three were treated with intravenous immunoglobulin and high dose aspirin (30–50 mg/kg per day), followed by low dose aspirin (3–5mg/kg per day) for 8 weeks. All made a full recovery including normal echocardiograms.

Comment: The authors speculate that the false-positive SARS-CoV-2 IgG could be due to cross-reactive antibodies triggered by Kawasaki Disease or triggered by other coronaviruses. They discount the possibility that the results were related to the administration of IVIG, which had been obtained from healthy Hong Kong blood donors months before its use, and long before the first case of COVID-19 was diagnosed in Hong Kong in late January 2020.

There needs to be caution in investigating pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS), in the light of these results, The authors recommend patients with positive SARS-CoV-2 serology but negative PCR should be further tested by microneutralization assay for the presence of neutralizing antibodies.

Davies, PRamnarayan, PLancetIntensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study9 Jul 2020UKEurope78Clinical - PIMS-TShttps://doi.org/10.1016/S2352-4642(20)30215-7

This multicentre observational study examines 78 children with PIMS-TS, admitted to 21 of the 23 PICUs in the UK between April 1 and May 10, 2020. The study team analysed routinely collected de-identified data submitted by clinicians from the individual PICUs.

The median age of patients was 11 years (IQR 8–14). There were 52 male patients (67%) and 61 patients (78%) were from ethnic minority backgrounds.

Clinical features: Common presenting features were fever in 78 (100%), shock in 68 (87%), abdominal pain in 48 (62%), vomiting in 49 (63%) and diarrhoea in 50 (64%). Rash was seen in 35 (45%) and conjunctivitis in 23 (29%).

Bloods: Of 35 patients tested for SARS-CoV-2 IgG serology, 33 were positive, and one of the two negative serology patients was PCR positive. 32 patients were PCR negative, with unknown serology and without a known COVID-19 contact. Over the first 4 days of admission there was a reduction in C-reactive protein (from a median of 264 mg/L on day 1 to 96 mg/L on day 4) and ferritin (1042 μg/L to 757 μg/L), whereas the lymphocyte count increased to more than 1·0 × 109 cells per L by day 3.

Outcomes: 36 (46%) patients were invasively ventilated and 65 (83%) needed vasoactive infusions; 57 (73%) received steroids, 59 (76%) received intravenous immunoglobulin, and 17 (22%) received biologic therapies. 28 (36%) had evidence of coronary artery abnormalities (18 aneurysms and ten echogenicity). Three children needed extracorporeal membrane oxygenation, and two children died.

During the study period, the rate of PICU admissions for PIMS-TS was at least 11-fold higher than historical trends for similar inflammatory conditions. Using these data and extrapolating from international child sero-prevalence data (Spain ~3% of children being infected, equivalent to 456,000 children in the UK) this would result in a conservative estimate of the risk of a child infected with SARS-CoV-2 subsequently being admitted to PICU with PIMS-TS as just under 2 per 10,000 infections.

Dufort, EZucker, H NEJMMultisystem Inflammatory Syndrome in Children in New York State29 Jun 2020USANorth America99Clinical - PIMS-TShttps://www.nejm.org/doi/full/10.1056/NEJMoa2021756?query=featured_coronavirus

This is a case series of 99 children (<21 years of age) from New York State with multisystem inflammatory syndrome in children (MIS-C). Of note some of these cases have been reported in small series (Cheung et al JAMA 2020). New York State Department of Health required hospitals that provide paediatric medical or surgical care to report potential cases of Kawasaki’s disease, toxic shock syndrome, or myocarditis or who were suspected to have MIS-C among persons younger than 21 years of age admitted since March 1, 2020, through the NYSDOH Health Emergency Response Data System. The clinical and laboratory characteristics of these reports were studied. Between March 1 and May 10 2020 191 cases were reported of which 95 met the criteria for MIS-C and 4 further were suspected.

Case definition: Confirmed cases were defined by the presence of both clinical and laboratory criteria. Suspected cases had clinical and epidemiological criteria. Clinical criteria were children <21 years of age with fever and needing hospitalisation with either; 1 or more of hypotension or shock, features of severe cardiac illness, or other severe organ failure. Or 2 or more of; maculopapular rash, non-purulent conjunctivitis, mucocutaneous inflammatory signs or acute GI symptoms with an absence of other cause.

Laboratory criteria: 1. General Criteria; Two or more of raised inflammatory markers and 2. Either positive SARS CoV2 RNA at time of presentation or within 4 weeks or detection of specific antibody.

Epidemiological criteria: In 6 weeks prior to exposure close contact with a person with confirmed or clinically consistent Sars CoV2 infection or travel to or resident in an area with ongoing community transmission.

Baseline characteristics: 53 (54%) were male. Age range was 0-5 years (31%), 6 to 12 year (42%) and 13 to 20 years (26%). 78 patients had data on race with 29 (37%) were white, 31 (40%) were black, 4 (5%) were Asian, and 14 (18%) were of other races. 36 patients had a preexisting condition, 29 had obesity. 24 (24%) had a Covid-19–compatible illness a median of 21 days (interquartile range, 10 to 31) before hospitalization, 38 (38%) had exposure to a person with confirmed Covid-19, and 22 (22%) had direct contact with a person who had clinical Covid 19.

Symptoms : Described in detail in the study. Prevalence of dermatologic symptoms was highest among children 0 to 5 years of age, and the prevalence of myocarditis (diagnoses and clinical) was highest among the adolescents.

Treatment : Of 99 patients, 79 were treated in ICU. 69 had IVIG, 63 received systemic glucocorticoids, 48 received both systemic glucocorticoids and IVIG. 9 patients had coronary aneurysm

Outcome : As of May 15, a total of 76 patients (77%) had been discharged and 21 (21%) were still hospitalised. Unfortunately 2 patients died in the hospital. Both were intubated and ventilated, once received ECMO. Neither received IVIG, systemic glucocorticoids, or immunomodulators.p

Feldstein, LRRandolph, AGNEJMMultiststem Inflammatory Syndrome in U.S. Children and Adolescents29 Jun 2020USANorth America186Clinical - PIMS-TShttps://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.nejm.org%2Fdoi%2Ffull%2F10.1056%2FNEJMoa2021680&data=01%7C01%7CA.Munro%40soton.ac.uk%7C44a8f00e84024fc3091408d81ce42e9c%7C4a5378f929f44d3ebe89669d03ada9d8%7C0&sdata=bQRL8Sx61R5%2FkQST67%2FVl9CZj8puJPfyKJCftB6Q9ec%3D&reserved=0
Hameed, SJogeesvaran, K HRadiologySpectrum of Imaging Findings on Chest Radiographs, US, CT, and MRI Images in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19.25 Jun 2020UKEurope35Clinical - PIMS-TShttps://pubs.rsna.org/doi/10.1148/radiol.2020202543
Riollano-Cruz, MPaniz-Mondolfi, AJ Med VirolMultisystem Inflammatory Syndrome in Children (MIS‐C) Related to COVID‐19: A New York City Experience25 Jun 2020USANorth America15Clinical - PIMS-TShttps://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.26224

This retrospective case series describes 15 patients presenting to Mount Sinai Hospital in New York between 24th April and 19th June 2020. Patients were identified by presentation to hospital with clinical features meeting the criteria for MIS-C (known in the UK as PIMS-TS) as defined by the Centers for Disease Control and Prevention Emergency Preparedness and Response, and the New York City Health Department. The mean age of the 15 patients was 12 years, with a range of 3 to 20 years. 11 patients (73%) were male, and 10 patients (66%) identified as Hispanic or Latino.

Clinical features: All patients had a fever at admission and 13/15 (87%) had gastrointestinal symptoms including abdominal pain, vomiting and diarrhoea. Respiratory symptoms were far less common, with cough or sore throat only occurring in 3/15 (20%) of cases. Other features at admission included rash in 7/15 (47%), conjunctivitis in 4/15 (27%) and swollen hands and feet in 4/15 (27%).

COVID-19 status: 7/15 (47%) tested positive for SARS-CoV-2 from a nasopharygeal or respiratory specimen during admission, and 2/15 (13%) had a positive test in the month prior to admission. 15/15 (100%) of patients were positive for COVID-19 antibodies.

Radiology: CXR at admission showed non-specific findings in 7/15 (47%), reactive airway disease in 4/15 (27%), pleural effusions in 4/15 (27%) and were normal in 3/15 (20%). Echocardiogram was abnormal in 12/15 (80%): 4/15 (27%) had reduced LV function, 3/15 (20%) had reduced biventricular function and 3/15 (20%) had coronary artery abnormalities.

Bloods: 13/15 patient (87%) presented with lymphopenia, and 14/15 (93%) had elevated fibrinogen. During admission 15/15 cases (100%) had a raised CRP and D-dimer, 14/15 (93%) had a raised ESR and 13/15 (87%) had a raised ferritin. IL-6 and IL-8 were elevated in 15/15 patients (100%) whereas 0/15 (0%) had an elevated IL-1 (which tends to be raised in Kawasaki disease).

Treatment: 15/15 patients (100%) received prophylactic enoxaparin until 2 weeks post-discharge. 12/15 patients (80%) received tocilizumab (anti-IL-6 antibody), 12 (80%) were given IVIG, 3 (20%) received steroids, 2 (13%) initially received Anakinra (IL-1 receptor antagonist),and 2 (13%) patients were treated with Remdesivir. Outcomes were not analysed according to treatment received.

Outcomes: 14/15 patients (93%) were admitted to PICU. 3 patients (20%) needed mechanical ventilation, another 5 patients (33%) required non-invasive ventilation, and 8 patients (53%) needed inotropic support. At the time of publication 13 patients had been discharged, 1 was still an inpatient and 1 had died.

Chiu, J. S., Samuels-Kalow, MPediatr Cardiol. Kawasaki Disease Features and Myocarditis in a Patient with COVID-1915 Jun 2020USANorth America1Clinical - PIMS-TShttps://link.springer.com/article/10.1007/s00246-020-02393-0
Capone, CDavidson, KJ. PediatrCharacteristics, Cardiac involvement, and Outcomes of Multisystem Inflammatory Disease of Childhood (MIS-C) Associated with SARS-CoV-2 Infection14 Jun 2020USNorth America33Clinical - PIMS-TShttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293762/

This is a single-centre retrospective case series of 33 sequentially hospitalized febrile paediatric patients with CDC case definition for Multisystem Inflammatory Disease of Childhood (MIS-C) and WHO criteria for Multisystem Inflammatory Syndrome (MIS) admitted to Cohen Children's Medical Center, Queens, NY from April 17, 2020 through May 13, 2020. All cases were positive for SARS-CoV-2 by detection of serum antibodies or nucleic acid from a nasopharyngeal specimen. Patients with COVID-like lower respiratory tract involvement were excluded. The peak of hospitalizations occurred approximately five weeks after the peak of hospitalizations with acute COVID-19. Patients were predominantly male (20, 61%) and non-Hispanic (24, 73%) with a median age of 8.6 years (IQR 5.5-12.6). Most patients were previously healthy but a higher proportion were overweight (2,6%) or obese (12, 39%) compared with the regional childhood obesity rate of 18%. 

Patients presented with a median of 4 days (IQR 3-5) of fever and almost all (32, 97%) had gastrointestinal symptoms (including diarrhoea, vomiting and abdominal pain) as well as other organ system involvement. 21 (64%) patients fulfilled complete criteria for KD and most patients with complete KD criteria, had shock (16, 76%). 

All patients had negative blood cultures and multiplex nucleic acid amplification test for multiple respiratory pathogens except 1 patient in whom influenza virus detected. 26 (79%) patients needed intensive care and 6 (18%) required mechanical ventilation. 58% had myocardial dysfunction and 76% required vasoactive medications. Coronary artery aneurysm was identified in 5 (15%) and dilation was detected in 3 (9%) patients.

All patients were treated with IVIG, 88% received aspirin, and 70% were given a corticosteroid and 42% were given Enoxaparin. 24% of patients exhibited a partial response to these treatments and received a biologic modifying medication (Anakinra, Tocilizumab, Infliximab). Most patients demonstrated rapid clinical improvement. No patients died. Median length of hospital stay was 4 days (IQR 4, 8). At hospital discharge, mild cardiac dysfunction was still present in 9 of 19 patients. This case series shares similarities with smaller international case series reported as Kawasaki-like disease and hyperinflammatory shock syndrome. In all these studies, most patients had antibodies against SARS-COV2 virus, suggestive of a post-infectious, immunologically mediated pathophysiology. The authors suggest that the latent period between the peak of paediatric cases of COVID-19 and MIS-C suggests that MIS-C has a post-infectious, possibly immunologically mediated pathogenesis.

Despite clinical similarities with KD, differences include the predominance of gastrointestinal symptoms, an older age range (8.6 year in MIS-C patients compared with a median age of 2.5 years for patients with KD), markedly elevated inflammatory markers, higher proportion of patients with shock and/or impaired cardiac function (76%) than in other KD studies (less than 3% shock reported), and the lack of thrombotic events in the case series patients. This suggests that MIS-C may be a syndrome distinct from KD. Acute COVID-19 with "cytokine storm" further complicates differentiation of these presentations.  

Further study is needed to shed light on the pathophysiology, treatment options, and outcomes of MIS-C.

Foong Ng, KTang, JWTJournal of Medical VirologyCOVID-19 Multisystem Inflammatory Syndrome in Three Teenagers with Confirmed SARS-CoV-2 Infection13 Jun 2020UKEurope3Clinical - PIMS-TShttps://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.26206
Kaushik, SMedar, SJ PediatricsMultisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 Infection: A Multi-institutional Study from New York City13 Jun 2020USANorth America33Clinical - PIMS-TShttps://www.jpeds.com/action/showPdf?pii=S0022-3476%2820%2930747-2

This retrospective observational study details clinical characteristics, therapies and outcomes of a multicentre cohort of 33 children with Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 admitted to PICUs at 3 tertiary care children’s hospitals in New York City between 23 April and 23 May 2020.Study design: Patients aged 1 month to 21 years admitted to 3 NYC PICUs (at Children’s Hospital at Montefiore, Mount Sinai Kravis Children’s Hospital and Jacobi Medical Center) with confirmed SARS-CoV-2 infection (positive nasopharyngeal swab RT-PCR or antibody assay) meeting criteria for MIS-C (US CDC case definition, formalised on 14 May 2020, used: age < 21 yrs presenting with fever, laboratory evidence of inflammation and evidence of clinically severe illness requiring hospitalisation, with 2 organ involvement, plus no alternative plausible diagnosis, plus positive for current/recent SARS-CoV-2 infection or COVID-19 exposure within 4 wks prior to onset of symptoms). During the study period there were additional suspected patients with similar presentations and management without confirmed SARS-CoV-2 infection/exposure who were excluded; only cases with confirmed infection by RT-PCR/antibody assay were included.

Study population: 33 children met the inclusion criteria at the 3 centres. Median age 10 years (IQR 6-13), 20/33 male (61%), median BMI 18.6 kg/m2 (IQR 15.9-22.9), 2/33 obese (6%, BMI > 30 kg/m2). 15/33 Hispanic/Latino (45%), 13/33 black (39%), 3/33 white (9%), 1/33 Asian (3%), 1/33 other (3%). 16/33 comorbidities (48%) (most common comorbidity was asthma). 8/33 (24%) had had contact with an ill person, 5/33 (15%) had had contact with a confirmed COVID-19 case.

Clinical features: Fever 31/33 (94%), mucocutaneous involvement 7/33 (21%), conjunctivitis 12/33 (36%), rash 14/33 (42%), abdominal pain 21/33 (64%), nausea/vomiting 23/33 (70%), diarrhoea 16/33 (48%), dyspnoea 11/33 (33%), dizziness 3/33 (9%). Duration of symptoms prior to admission 4.5 days (IQR 3-6). 21/33 (64%) were hypotensive on admission.

Admission blood results: Medians (IQR in brackets): WBC 11,000/L (8450-14,400), lymphocytes 1,100/L (600-1,300), CRP 250 mg/L (156-302), ESR 53 mm/hr (28-77), procalcitonin 5.4 ng/mL (1.8-16.7), ferritin 568 ng/mL (340-954), fibrinogen 627 mg/dL (455-782), D-dimer 3.7 g/mL FEU (2.4-5.1), BNP 388 pg/mL (75-1086), pro-BNP 4328 pg/mL (2117-13370), troponin T 0.08 ng/mL (0.02-0.17), IL-6 200 pg/mL (56.4-330), IL-8 41.7 pg/mL (25.1-54.4), creatinine 0.6 mg/dL (0.4-1.1).

CXRs: Cardiomegaly 10/33 (30%), focal or bilateral pulmonary opacities 11/33 (33%).

Echocardiograms: Performed in 32/33 (97%). Pericardial effusion 15/32 (47%), median LVEF 47% (IQR 40-53). LVEF < 30% 4/32 (13%), LVEF 30-50% 17/32 (53%), LVEF > 50% 11/32 (34%). 24/32 had a second echocardiogram prior to discharge: of those with initial LVEF < 50%, 20/21 (95%) had recovery of ventricular function with normal EF. Median pre-discharge LVEF 58% (IQR 55-62). A detailed table is supplied for the 21 patients with LVEF < 50%, including BNP/troponin levels, drug treatment by patient and the 8/21 who had prominent coronary arteries on echo.

Treatment in PICU: 18/33 received IVIg (55%), 17/33 corticosteroids (52%), 12/33 tocilizumab (35%), 7/33 remdesivir (21%), 4/33 Anakinra (12%), convalescent plasma therapy 1/33 (3%), 17/33 vasopressor/inotropes (52%) (median duration of vasopressor use 72 hrs (IQR 48-110), norepinephrine most commonly used agent), 8/33 aspirin (24%), 21/33 diuretics (64%). Anticoagulation was used in all patients: prophylactic dose enoxaparin 5/33 (15%),therapeutic dose enoxaparin 27/33 (82%), therapeutic dose unfractionated heparin 1/33 (3%). Empiric antibiotic coverage for < 48 hrs in 14/33 (42%) and > 48 hrs in 15/33 (45%). 5/33 (15%) required invasive mechanical ventilation. 2/33 (6%) required mechanical circulatory support: 1 ECMO (5-yr-old) and 1 intra-aortic balloon pump (20-yr-old).

Outcomes: 32/33 (97%) patients were discharged home with median PICU stay of 4.7 days (IQR 4-8) and hospital stay of 7.8 days (IQR 6-10). 1/33 (3%) died (ischaemic brain infarction with subarachnoid haemorrhage on day 6 of ECMO).The authors conclude that rapid, complete clinical and myocardial recovery was almost universal in their study. They hypothesise that this novel COVID-19 MIS-C is predominantly an antibody-mediated or other immune cell-mediated cytokine storm, with some contribution from direct myocardial injury. They note the lower morbidity in their cohort relative to recent European studies

Schnapp, AMolho-Pessach, VJ Eur Acad Dermatol VenereolIntroductory histopathologic findings may shed light on COVID19 pediatric hyperinflammatory shock syndrome13 Jun 2020IsraelMiddle East1Clinical - PIMS-TShttps://onlinelibrary.wiley.com/doi/epdf/10.1111/jdv.16749
Ramcharan, TChikermane, APediatr Cardiol.Paediatric Inflammatory Multisystem Syndrome: Temporally Associated with SARS-CoV-2 (PIMS-TS): Cardiac Features, Management and Short-Term Outcomes at a UK Tertiary Paediatric Hospital12 Jun 2020UKEurope15Clinical - PIMS-TShttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289638/

This retrospective case-series on the cardiac manifestations of PIMS-TS from a UK Paediatric Centre (Birmingham); reinforces and highlights some of the clinical features reported elsewhere.

15 patients meeting the definition of PIMS-TS were identified over one month, between 10th of April and 9th of May, at Birmingham Women’s and Children’s NHS Foundation Trust. Patient demographics were consistent with other larger reports; patient age 8.8yrs (IQR 6.4-11.2years); which the authors highlight is older than the average age of children affected by Kawasaki’s disease in the UK and consistent with previous literature on PIMS-TS. Furthermore; this cohort were predominantly male (11/15 (73%) and all (100%) were from African/Afro-Caribbean, South Asian, mixed or other minority ethnic groups; the authors highlight that this is disproportionate to the ethnic demographics of children within the region.

The paper focuses on cardiac investigations and highlights that all patients in this cohort had evidence of cardiac involvement. 60% (9/15) had ECG abnormalities;

primarily T-wave abnormalities; 93% (14/15) had coronary artery abnormalities on echo. Coronary abnormalities were detailed as ‘prominent’, ‘dilated’ or ‘aneurysmal’. Aneurysms were seen in only one patient. Left ventricular dysfunction was evidenced in 80% and this was reflected in the needs for cardiovascular support (necessary in 10/15 (67%) of patients and an equal number requiring PICU admission).

Reassuringly all patients survived and were discharged after a median hospital stay of 12 days (IQR 9-13days). In the 12 patients who had completed their first clinic review (1 week following discharge), all had stable cardiac function and no new coronary changes.

Pouletty, AMelki, IAnn Rheum Dis Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort11 Jun 2020FranceEurope16Clinical - PIMS-TShttps://ard.bmj.com/content/annrheumdis/early/2020/06/11/annrheumdis-2020-217960.full.pdf

This is a retrospective clinical case series, comprising 16 children from the Paris region, France, who were reported to two national networks of children with rare auto-immune and rheumatologic disorders between 7 and 30 April 2020. Median age was 10 years (IQR (4.7 to 12.5)) and sex-ratio was 1. Four children were overweight and 2 had asthma.

SaRs-CoV-2 was detected in either nasopharyngeal secretion or stool samples in 11 cases (69%), while the remaining five cases included in the series had close exposure to a SARS-CoV-2 PCR-positive individual.

Ten patients (62%) had Kawasaki Disease, defined by persistent fever over 5 days associated with at least four of the five following criteria: conjunctivitis, lymphadenopathy, skin rash, red and cracked lips, inflammation of hands and feet; whilst the remaining 6 were described as having “incomplete” Kawasaki Disease.

Clinical features: Cough and dyspnoea occurred in 2 (12%) and anosmia in 1 (6%), whereas 13 (81%) had gastrointestinal signs. Neurological signs (headache or aseptic meningitis) occurred in 9 (56%). Thirteen (81%) had skin rash, 11 (68%) had erythema/oedema of hands and feet, 15 (94%) had conjunctivitis, 14 (87%) had dry cracked lips and 6 (37%) had cervical lymphadenopathy.

Eleven (69%) children developed haemodynamic failure and 9 (56%) developed acute renal failure. 7 patients (44%) developed Kawasaki shock syndrome.

Laboratory investigations: Inflammatory biomarkers were highly elevated in all patients, with median C-reactive protein (CRP) 207mg/L (IQR 162 to 236). Ferritin (median 1067 μg/L (IQR 272 to 1709)) was abnormal in 12 of 14 tested patients, and highly elevated (>500μg/L) in 50% of cases. Myocardial enzymes were elevated in 11 patients.

Imaging: Only 5 (31%) children had an abnormal chest X-ray. Eleven (69%) had an abnormal cardiac ultrasound, including coronary artery dilatation and signs of myocarditis or pericarditis.Treatment: Fifteen patients (94%) were treated with intravenous immunoglobulin. Additional treatments included steroids in 3 (19%) and aspirin in 15 (94%). Seven children (44%) were admitted to ICU.

Outcome: Median duration of symptoms from onset until abatement of fever was 9 days (IQR 8 to 13). No patient died. All made a recovery, but two have persistent mild cardiac dysfunction due to myocarditis.

This paper makes an important contribution to the clinical literature about Paediatric Multisystem Inflammatory Syndrome temporally associated with COVID-19.

The authors compared their patients to an historical series of 220 French children diagnosed with Kawasaki disease between 2005 and 2020. The children in the historical series were significantly younger and had significantly higher platelet and lymphocyte counts. Importantly, the patients reported in the present study had a significantly higher frequency of cardiac complications than children in the historical series.

The authors also attempted to subdivide the small cohort into a severe and non-severe group, but the comparison does not appear to serve a useful purpose.

Blondiaux EDucou le Pointe HRadiologyCardiac MRI of Children with Multisystem Inflammatory Syndrome (MIS-C) Associated with COVID-19: Case Series9 Jun 2020FranceEurope4Clinical - PIMS-TShttps://pubs.rsna.org/doi/10.1148/radiol.2020202288

The authors describe 4 children who developed MIS-C who required admission to PICU because they had developed myocarditis and signs of cardiogenic and/or septic shock syndrome. One required mechanical ventilation. All 4 recovered.

Mean age was 9year (range 6-12years), and cardiac features developed <1 week after onset of covid-19 symptoms of abdominal pain and rash. 3 of the 4 had chelitis or conjunctivitis. None had experienced any respiratory symptoms.

Nasopharyngeal swabs and respiratory and stool samples were all negative for covid-19 using RT-PCR. All 4 had positive IgG to covid-19 and one also had positive IgM antibody. The clinical and laboratory findings and treatment given are tabulated, and a further table gives the cardiac MRI findings with images. MRI was undertaken during the acute phase in 3 and recovery phase in the 4th patient. The main MRI finding was of cardiac hyperaemia and oedema, without evidence of fibrosis. There were no coronary artery abnormalities.

The authors contrast the diffuse myocardial findings of MIS-C in children with the cardiac effects of covid-19 in adults, in whom it causes focal myocardial fibrosis/necrosis. They highlight that their findings point to inflammatory infiltration of the interstitial myocardium similar to that seen in Kawasaki disease. They suggest that this points to an inflammatory immune response to an antigen rather than to viral infiltration. The timescale of peak inflammatory response at 10 days after onset of symptoms and resolution by 20 days is also similar Kawaski disease. In contrast to Kawasaki disease, MISC-C affects an older age group and was not associated with arterial changes in this series.

Cheung, EMilner, JJAMAMultisystem Inflammatory Syndrome Related to COVID-19 in Previously Healthy Children and Adolescents in New York City8 Jun 2020USANorth America17Clinical - PIMS-TShttps://jamanetwork.com/journals/jama/fullarticle/2767207?appId=scweb

This is a case series of 17 children, admitted to a hospital in New York city, between April 18th and May 5th 2020 with features of Multisystem Inflammatory Syndrome Related to COVID-19.

Patients included in this series were i. less than 21 years old, ii. presented with a clinical syndrome characterized by prolonged fever, systemic inflammation, shock, end-organ dysfunction, or symptoms reminiscent of Kawasaki Disease or Toxic Shock Syndrome and iii. had evidence of recent (SARS-CoV-2) infection. The baseline characteristics of these children were; median age 8 years (1.8-16), 8 were male (47%); 12 were classified white (70.1%), 4 black (23.5%), 1 Asian (5.9%).

Presentation: All had fever, with median duration of 5 days. 14/17 had GI symptoms. Mucocutaneous findings were common (12 rash, 11 conjunctivitis, 9 lip redness/swelling). 3 were hypoxic at presentation, and 13 had shock. 8 met criteria for KD and 5 for incomplete KD.Investigations: 8 patients tested positive for SARS-CoV-2 by RT-PCR and 9 by serology.

Xrays: 14 had abnormal chest radiograph findings, most commonly bilateral, interstitial opacities.

Bloods: mean values for a wide variety of investigations shown in paper in table 2. Mainly group were lymphopenic with raised ferritin, d dimers, clotting times, and troponin. Cardiac: ECG of 16 patients showed nonspecific ST/T-wave abnormalities in 10 and attenuated QRS voltage in 1. Dysrhythmias were noted in 3. Admission echos showed normal to mildly decreased left ventricular function in 11, or moderate or more ventricular dysfunction in 6. All patients had normal coronary arteries by measurement, though coronary arteries were described as prominent or echogenic in 7. However one patient (aged 4 years) developed a medium-sized aneurysm (z score, 5.2) of the left anterior descending coronary artery. This patient presented with fever, diarrhea, and shock, with no additional features of KD.Treatment: 15/17 patients were admitted to PICU; vasoactive support was required in 10. Treatment was varied, 14 received steroids (either methylprednisone or hydrocortisone, prednisolone numbers of each not given). 13/17 received IVIG including 3 patients who did not receive steroids and 8 who met criteria for KD. One patient received tocilizumab.

Outcome: All patients discharged home with no fatalities.

Comparison with other PIMS TS cohorts:

Reports of hyperinflammatory syndrome in children during the Sars CoV2 outbreak has been reported in France, Italy, UK and US. (see https://dontforgetthebubbles.com/pims-ts/) This cohort used the CDC definition, which is broadly similar to RCPCH and WHO, though in the US paediatrics < 21 years of age.

Like the other cohorts, the age range is older than typically seen in Kawasaki Disease. Fever and GI symptoms are very common. Mucocutaneous signs were also common. Children presented very unwell, with many needing PICU care (88% in this study). Treatment used included IVIG and steroids.

Unlike other cohorts where black ethnicity was pronounced, 70% of this cohort was classified as white. It would be useful to know the demographic breakdown of the local paediatric population who attend this hospital.

Whittaker, ELevin, MJAMAClinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-28 Jun 2020UKEurope58Clinical - PIMS-TShttps://jamanetwork.com/journals/jama/fullarticle/2767209

This paper provides a detailed description of the clinical and laboratory features of 58 children diagnosed with PIMS-TS from 8 hospitals in England between March 23rd and May 16th 2020. All children fulfilling the UK, WHO or CDC criteria for PIMS-TS / MIS-C were included; evidence of SARS-CoV-2 infection was not required for inclusion. Features of this group were compared with previous data from children with Kawasaki Disease (KD), KD shock syndrome (KDSS) and toxic shock syndrome (TSS).

Of the 58 patients, 45 (78%) had evidence of SARS-CoV-2 infection (RT-PCR (15) and or IgG (40)). 33 (57%) were female. 22 (38%) were of black race, 18 (31%) asian. The majority were previously well; only 7 had co-morbidities (3 with asthma, 1 epilepsy, 1 neuro-disability, 1 sickle cell trait, 1 alopecia)

All patients had fever (range 3-19 days). Gastrointestinal symptoms were common (abdominal pain (53%), diarrhoea (52%), vomiting (45%)) whilst respiratory symptoms were relatively uncommon (21%) and 15 (26%) had headache. 

Only 13 (22%) of patients fulfilled criteria for KD; 8 (14%) had coronary artery aneurysm, 26 (45%) conjunctival injection, 30 (52%) rash, 17 (29%) mucous membrane changes, 9 (16%) lymphadenopathy, and 9 (16%) swollen hands and feet. Half of patients developed shock. Laboratory findings were consistent with marked inflammation (mean CRP 229 mg/L (IQR 156-338), ferritin 610 μg/L (359-1280), fibrinogen 5.7 g/L (4.4-7), D-dimer 3578 ng/mL (2085-8235)) with neutrophilia (13 x 10^9 (10-19)). Evidence of myocardial injury was common with troponin elevated in 34/50 (68%) and NT ProBNP in 24/29 (83%). Low haemaglobin (92 g/L (83-103)), lymphocyte (0.8 x 10^9 (0.5-1.5) and platelet levels (151 x 10^9 (104-210)) were also observed. 

Half of patients were admitted to a critical care unit; 25 (43%) requiring mechanical ventilation, 27 (47%) inotropes and 3 (5%) ECMO. A range of treatments were given including IVIG (71%), steroids (64%), anakinra (5%) and infliximab (14%). 13 (22%) recovered without immunomodulatory treatment, whilst 60% received >/= 2 and  16% >/= 3 agents. To the last date of follow up only one child had passed away. p

The authors suggest three clinical patterns of PIMS-TS based on the patients included in this series:    (1) persistent fever and elevated inflammatory markers (without KD, shock or organ failure) - 23 patients here   (2) fever and shock, often with myocardial dysfunction - 29 patients    (3) children fulfilling criteria for KD - 7 patients (13 if aneurysm included in criteria). 

Compared with children with KD, KDSS and TSS, children with PIMS-TS were older (median age 9 (IQR 5.7-14)) with higher CRP and lower haemaglobin. Compared with those with KD and KDSS, PIMS-TS patients in this series had higher neutrophil count, ferritin and troponin with lower platelet and lymphocyte counts. Compared with pre-COVID-KD cases children with PIMS-TS KD were older and had higher markers of inflammation and myocardial injury. 

This is the most detailed clinical report of PIMS-TS to date. The findings here demonstrate a syndrome with a wide spectrum of signs, symptoms and severity with some overlap with KD, KDSS and TSS. PIMS-TS is characterised by marked inflammation with myocardial dysfunction and often shock necessitating ICU admission for inotropic support, mechanical ventilation and, in a small number of patients, ECMO. Treatment with immunomodulatory agents similar to those used in KD has been employed and only one death had occurred at the time of the report. Differences in clinical and laboratory profile compared with KD, KDSS and TSS, suggests= that PIMS-TS is a unique entity, potentially arising from a maladaptive acquired immune response to SARS-CoV-2 infection. 

Toubiana, JAllali, SBMJKawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study3 June 2020FranceEurope21Clinical - PIMS-TShttps://www.bmj.com/content/369/bmj.m2094

This cohort study looks at a cluster of patients diagnosed with Kawasakis disease at a hospital in Paris between April 27th and May 11th. During this time they admitted 21 children with a diagnosis of Kawasakis or incomplete Kawasakis, with a median age of 7.9yr and 12/21 female.

Clinical features: All children presented with persistent fever and with initial GI symptoms (vomiting and diarrhoea) with over half fulfilling complete KD criteria (11/21, 52%). The majority were irritable (12/21, 57%) and myocarditis was common (16/21, 76%). Coronary artery dilation was seen in 5/21 (24%) but no aneurysms seen. 8/18 who had chest imaging had lung changes.Bloods: Inflammatory markers were significantly raised, with a median CRP of 253, PCT 22.5 and IL-6 170. Interestingly mean platelet count was 499 (but up to 838). Median troponin 282 and D dimer 4025 (up to 19330). Ferritin not reported.

COVID-19 status: 8/21 tested positive on swab and 19/21 had positive serology Treatment: All were given IVIg, following which 5/21 still had fever 36hrs afterwards. They were given a second dose of IVIg and steroids. 15/21 required inotropic support and 11/21 required intubation/ventilation.

Outcomes: Median length of stay was 8 days (rage 5 – 17). There were no deaths.Three subsequent studies have confirmed very similar presentations of this hyperinflammatory syndrome (PIMS-TS) in children, with initial abdominal pain, fever, diarrhoea and vomiting, progressing to a picture similar to Kawasakis disease but with a significant number developing shock and significant cardiac involvement.

Grimaud, MOualha, MAnnals of Intensive careAcute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children.1 Jun 2020FranceEurope20Clinical - PIMS-TS https://annalsofintensivecare.springeropen.com/track/pdf/10.1186/s13613-020-00690-8

This is a retrospective observational study of 20 children who were admitted to paediatric intensive care units across four academic tertiary centres in Paris, four weeks after the start of French lockdown. None of the children had existing co-morbidities nor a history of symptomatic COVID-19 infection.

All patients were less than 18 years old and presented with hypotensive shock and acute myocarditis.

All children had the same presenting complaint- severe abdominal pain, vomiting and fever, for an average of 6 days previously (1-10). On admission to PCIU all children had a raised CRP, (median 251) and procalcitonin, (median 46). p

All children had myocarditis, defined as: elevated troponin, ST segment elevation or depression on ECG and regional wall motion abnormalities with decreased left ventricular function on ECHO. Pericardial effusion was found in four children. All children but one required inotropic support for a median of 3 days (1-7). Eight children required mechanical ventilation for 1-7 days.

Fourteen children had transient acute renal failure but none required renal replacement therapy.

SARS-CoV-2 PCR and serology were positive for 10 and 15 children respectively. One child had a negative PCR and serology but typical SARS-CoV-2 chest CT scan changes. No other bacterial or viral infections were identified.

All children had at least one feature of Kawasaki disease along with a fever, skin rash (10), conjunctivitis (6), cheilitis (5), adenitis (2).

All children received intravenous immunoglobulin within 48hrs of admission and 18 were afebrile thereafter. Two children also received corticosteroids, the reason for this additional therapy is not documented in the article.

All children survived and were afebrile with a full left ventricular function recovery at the time of discharge from PICU.

Wolfler, AndreaZuccotti, GianvincenzoLancet Child Adolescent Health 2020Acute myocardial injury: a novel pattern in children with Covid-19 1 Jun 2020ItalyEurope9Clinical - PIMS-TShttps://doi.org/10.1016/s2352-4642(20)30168-1
Greene, ASinert, RAJEMToxic shock-like syndrome and COVID-19: A case report of multisysteminflammatory syndrome in children (MIS-C)31 May 2020USANorth America1Clinical - PIMS-TShttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274960/pdf/main.pdf
Miller, JMargolis, KGastroeneterologyGastrointestinal symptoms as a major presentation component of a novel multisystem inflammatory syndrome in children (MIS-C) that is related to COVID-19 a single center experience of 44 cases30 May 2020USANorth America44Clinical - PIMS-TShttps://www.gastrojournal.org/article/S0016-5085(20)34753-3/pdf

A retrospective case study of gastrointestinal symptoms in children with PIMS-TS (the authors call MIS-C). 44 children (age range 7months -20years, 20male), were identified with MIS-C between 18 April 2020 and 22 May 2020. The diagnostic criteria for MIS-C were not given. Gastrointestinal symptoms were present in 84.1% of children, all were febrile and 31/40 (70.5%) had a skin rash.

Importantly 13/44 (29.5%) of children had presented previously with only symptoms of different milder GI conditions.

22/44 50% children had cardiac dysfunction, 22/44 50% had shock requiring treatment with vasopressors, 13/44 29.5% had neurological symptoms, 11/44 25% needed supplemental O2, and 7/44 had acute kidney injury.

Investigations showed markedly elevated inflammatory markers in all and half the children had elevated transaminases. GI imaging was undertaken in 15, 10/12 children had abnormal ultrasounds and 2/3 abnormal CT/MR

The authors conclude that PIMS-TS (MIS-C) should be considered in children with prominent GI symptoms and a history of Covid-19 infection. They also suggest long term follow up may be warranted for IBD surveillance.

Choitos, KJohn, AJ Pediat Inf Dis SocMultisystem Inflammatory Syndrome in Children during the COVID-19 pandemic: a case series26 May 2020AmericaNorth America6Clinical - PIMS-TShttps://doi.org/10.1093/jpids/piaa069

This retrospective and prospective multi-centre cohort study from 53 participating hospitals in 26 states looked at 234 patients under 21 years of age that met criteria for multi system inflammatory syndrome in children (MIS-C), between March 15 and May 20th

The median age of the patients was 8.3years old and 62% (115) were male. Fifty one patients (27%) had an underlying medical condition. In terms of confirmation of SARS_CoV-2 infection - 70% were positive for RT-PCR and/or antibody testing.  Of a small subgroup of 14 patients with Covid-19 symptoms before MIS-C, the median time between Covid-19 symptom to MIS-C was 25 days (6-51 days).

Criteria for MIS-C were based on CDC guidelines (in brief, requiring hospitalisation, at least two systems involved, fever of at least 24 hours and either lab confirmed SARS_CoV-2 infection (via RT-PCR or antibody testing) or an epidemiological link to a person with Covid-19 within 4 weeks before onset of symptoms).

Although MIS-C criteria was at least 2 system involvement, 71% had involvement of four organ systems or more. The most frequent systems in order were gastrointestinal (92%) followed by cardiovascular (80%), haematological (76%) and respiratory (70%). Blood changes observed included lymphocytopaenia in 80% of patients, and an elevated CRP in 91%.

Looking at similarity and overlap with Kawasaki disease, 40% of patients had either fever for at least 5 days and 4-5 of Kawasaki's disease-like features or 2-3 Kawasaki's disease-like features with additional lab or echocardiographic findings. Common symptoms similar to Kawasaki disease bilateral conjunctival infection in 103 (55%), oral mucosal changes in 78 (42%), peripheral extremity change in 69 (37%), rash in 110 (59%), cervical lymphadenoapthy (>1.5cm diameter) in 18 (10%). Differences between MIS-C and Kawasaki's disease groups include an older age group and a different cardiovascular involvement (more likely myocardial dysfunction) in MIS-C patients.The majority of patients required ICU admission (n=148, 80%) with one in five patients needing invasive mechanical ventilation. Eight patients received ECMO support.

Treatment included IVIG in 77% and systemic glucocorticoids in 49%. There were four deaths (two of which had received ECMO). At the time of writing the paper, 70% of patients had fully recovered with 28% still in hospital.

Chang, AHicar, MmedRxivKawasaki Disease serum responses against SARS-CoV-2.26 May 2020United StatesNorth America14Clinical - PIMS-TShttps://www.medrxiv.org/content/10.1101/2020.05.24.20111732v1
Labe, PMahe, EJ Eur Acad Dermatol VenereolErythema multiforme and Kawasaki disease associated with COVID-19 infection in children26 May 2020FranceEurope2Clinical - PIMS-TShttps://onlinelibrary.wiley.com/doi/epdf/10.1111/jdv.16666

This is a retrospective case-series from the United Kingdom of children with neurological symptoms, identified from a larger cohort (n = 55) of SARS-CoV-2 positive children. Of the 55 children, 27 had features of paediatric multisystem inflammatory syndrome (PIMS-TS) and of these, 4 had neurological symptoms.

Clinical Features: The four children had a median age of 12 years (range 8-15 years) and interestingly, two children were of South Asian ethnicity and two of Afro-Caribbean ethnicity. Of the neurological symptoms reported, encephalopathy (4/4), headache (3/4) and brainstem signs such as dysarthria or dysphagia (2/4) were most common. Peripheral nervous system involvement was present in all patients and included proximal muscle weakness (4/4) and decreased reflexes (2/2). Neurological symptoms occurred alongside a range of systemic symptoms but were part of the initial presentation in 2 children.

Investigations: The four children had a range of investigations, including a lumbar puncture (2/4), EEG (3/4), EMG (3/4), MRI (4/4). The CSF was acellular and SARS-CoV2 negative, mild excess of slow activity was seen on EEG, and EMG showed mild myopathic and neuropathic changes. Interestingly, MRI findings were consistent in all four children, and included signal changes in the splenium of the corpus callosum. Three of the four children also had T2 hyperintense lesions associated with restricted diffusion.

Treatments: Therapeutics given varied. Three children received treatment for PIMS-TS more broadly, including methylprednisolone (2/4), dexamethasone (2/4), IVIG (2/4), anakinra (2/4), and rituximab (1/4).

Outcome: At the time of follow-up (median 18 days, range 11-13 days), 2 patients remain in hospital and have residual lower limb weakness and require a wheelchair to mobilise, and 2 patients have been discharged ambulating without support.

Overall, this paper provides a thorough description of neurological features associated with SARS-CoV-2 infection in the setting of multisystem inflammation.

Waltuch, TGill, PAm J Emerg MedFeatures of COVID-19 post-infectious cytokine release syndrome in children presenting to the emergency department23 May 2020North AmericaNorth America4Clinical - PIMS-TShttps://www.ajemjournal.com/article/S0735-6757(20)30403-4/fulltext#t0005
Acharyya, BDas, DIndian Pediatr Novel Coronavirus Mimicking Kawasaki Disease in an Infant22 May 2020IndiaAsia1Clinical - PIMS-TShttps://www.indianpediatrics.net/COVID29.03.2020/CCL-00184.pdf
Deza Leon, MAsmar, BJPIDSCOVID-19–Associated Pediatric Multisystem Inflammatory Syndrome22 May 2020USANorth America1Clinical - PIMS-TShttps://academic.oup.com/jpids/advance-article/doi/10.1093/jpids/piaa061/5842067
Tullie, LCurry, JThe Lancet. Child & adolescent healthGastrointestinal features in children with COVID-19: an observation of varied presentation in eight children19 May 2020EnglandEurope8Clinical - PIMS-TShttps://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30165-6/fulltext#articleInformation

This is a case series of eight children referred to a single UK centre with symptoms of atypical appendicitis before rapid deterioration requiring hospitalisation and, in some cases, intensive care support. All were found to have evidence of terminal ileitis on imaging and did not require surgical intervention. Although the term is not used by the authors, all children in this case series appear to meet the case definition for Paediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS-TS). 4/8 children were PCR positive for Covid-19 on initial testing, increasing to 5/8 on repeat testing. Antibody testing is not reported.

Authors highlight the importance of imaging prior to surgery in suspected appendicitis during the COVID-19 pandemic. CT is superior to ultrasound in demonstrating a non-inflamed appendix.

Of note, 6 out of 8 were from Black or Asian ethnic group, this is in keeping with the increased rates of PIMS-TS reported among these ethnic groups. The weight of patients is not reported.

Clinical features: All patients presented with fever, abdominal pain, diarrhoea, and vomiting. All but one child had significantly raised CRP. Four patients developed multi-system inflammatory response with shock and required intensive care support, including one child with myocarditis who required ECMO.

Radiological features: Abdominal imaging demonstrated lymphadenopathy and presence of inflammatory fat throughout the mesentery, with thickening of the terminal ileum.Treatment: Four children were treated with IVIG and steroids for ‘atypical Kawasaki disease’, although two of these children did not have features of Kawasaki disease. All patients were treated with IV antibiotics and fluids.

Outcomes: At the time of writing 2 children had been discharged and the remainder were still hospitalised. There were no deaths.

Study period: 25 Apr 2020 to 2 May 2020

Age range: 4-16yr, mean: 10.6yr

This case series highlights that Covid-19, or PIMS-TS, may mimic appendicitis in children, due to inflammation of the terminal ileum. It is important to investigate appropriately to prevent unnecessary surgery on these children.

Licciardi,FMontin, DPediatricsSAR-Cov2-Induced Kawasaki -Like Hperinflamatory Syndrome: A novel Covid Phenotype in Children19 May 2020ItalyEurope2Clinical - PIMS-TShttps://pediatrics.aappublications.org/content/pediatrics/early/2020/05/19/peds.2020-1711.full.pdf
Belhadjer, ZWacker, JCirculationAcute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic17 May 2020France and SwitzerlandEurope35Clinical - PIMS-TShttps://onlinelibrary.wiley.com/doi/abs/10.1111/ctr.13889

A multi-centred retrospective case series studied the early outcomes for children admitted to intensive care for cardiogenic shock, left ventricular dysfunction and severe inflammatory state. The study involved 14 centres in France and Switzerland. The inclusion criteria were admission between 22nd March and 30th April 2020 with fever (>38.5°C), cardiogenic shock or left ventricular dysfunction (left ventricular ejection fraction<50% in the presence of an inflammatory state (CRP> 100 mg/mL).

In summary, left ventricular systolic dysfunction was present in all patients who experienced a low systolic blood pressure. The authors contrast this to Kawasaki disease, in which diastolic dysfunction predominates and only a third of patients experience left ventricular systolic dysfunction.

The authors suggest the rapid resolution of systolic dysfunction in conjunction with a mild to moderate troponin rise implies the mechanism of cardiac impairment associated with SARS-CoV2 in the paediatric population differs to that seen in the adult population. Due to the high BNP levels present in the case series a mechanism of myocardial oedema or stunning is suggested. Very high levels of Interleukin-6 were also seen and may be related to vasoplegia. It was hypothesised these significantly raised results could be caused by stretched cardiomyocytes and cardiac fibroblasts in conjunction with macrophage activation. However, further research would be required to determine the immune mechanisms involved and potentially guide treatment choices.

35 patients were included with a median age of 10 years (IQR 2-16 years), 18 were male. 31 patients were confirmed SARS-CoV2 positive by either a nasopharyngeal RT-PCR, faecal RT-PCR, tracheal swab, or serology using Chemiluminescent Microplate Immunoassay-CMIA technique. 2 other patients were SARS-CoV2 negative, however, had CT chest appearances consistent with SARS-CoV2 changes.

10 of the patients had an identified co-morbidity: 3 (8.5%) had asthma, 1 (3%) had lupus and 6 (17%) were overweight with a BMI greater than 25. There was no data regarding ethnic origin included.

Clinical features: 35 (100%) had fever, 35 (100%) Asthenia, GI symptoms 29 (83%), rhinorrhoea 15 (43%), respiratory distress 23 (65%), adenopathy 21 (60%), rash 20 (57%), meningism 11 (31%), chest pain 6 (71%), cardiogenic shock 28 (80%), ventricular arrhythmia 1 (3%). A large proportion of the patients had shock with low systemic blood pressure with limited information.

Radiology: 2 patients had CT chest appearances “typical” for those with SARS-CoV2.Bloods: CRP 241 mg/mL (IQR150-311) mg/mL, Troponin I 347 (IQR 186-1267) ng/L (normal <26ng/L), Creatinine Kinase 174 U/L (IQR 110-510), NT-proBNP 41484 pg/mL (IQR 35811-52475) (normal <300 pg/mL), BNP 5743 pg/mL (IQR 2648-11909) normal <100 pg/mL), D-Dimer 5284 ng/ml (IQR 4069-9095), Procalcitonin 36 ng/ml (IQR 8-99), WCC 16 X 10^3/L (IQR 12-23), Neutrophil count 13 X 10^3/L (IQR 8-19), Interleukin 6 135 pg/mL (IQR 87-175) (normal <8.5 pg/mL)

Treatments: All patients required intensive care management with 10 (28%) needing V-A ECMO for an average of 4.5 days (range 3-6), 28 (80%) needing inotropic medication, 22 (62%) invasive ventilation and 11 (32%) non-invasive ventilation.

25 (71%) were given intravenous immune globulin with 1 (3%) patient given repeated IVIG due to persistent fever 48 hours after the first dose. 12 (34%) received intravenous steroids, dose unclear, due to grading them high-risk with symptoms similar to an incomplete form of Kawasaki disease and 3 patients received interleukin 1 receptor antagonist (anakinra) due to a persistent severe inflammatory state. 23 patients received therapeutic heparin.

Outcomes: No patients died. All 10 patients requiring V-A ECMO were weaned off successfully. The average hospital stay was 8 days (IQR 8-14) with ICU duration of 7 days (3.7-10 days). At the time of publication 7 (20%) patients remained as an inpatient or had residual left ventricular dysfunction.

Complete recovery of left ventricular function, [left ventricular ejection fraction > 60% at day 7] was seen in 25 patients (71%) by an average of 2 days after admission. 5 (14%) had residual mild to moderate left ventricular systolic dysfunction with a left ventricular ejection fraction greater than 45%. This was measured on the last follow up, an average of 12 days after admission.

Other investigations were undertaken to assess cardiac function.

ECG: 1 patient (3%) had ST elevation on ECG.

Echocardiography results: 10 (29%) of patients had an ejection fraction below 30% on admission whilst 25 (71%) had an ejection fraction between 30 and 50%. Global hypokinesis was seen in 31 (89%) with an additional 3 (9%) patients had segmental wall hypokinesis. 1 (3%) patient had Takotsubo syndrome presentation with akinesis of the apical segment Pericardial effusions were diagnosed in 3 (9%) patients.

Coronary artery dilatation, defined as Z-score >2 adjusted for body temperature, was present in 6 patients (17%): 5 patients (14%) had dilatation of the left main stem and 1 (3%) had dilatation of the right coronary artery. Right ventricular function was normal, and no thrombi were seen. No coronary aneurysms have been seen, however, ongoing follow up is planned. Data was not presented regarding SARS-CoV2 antibodies, however, within the discussion it was noted that those who were serologically positive for SARS-CoV2 already had IgG antibodies suggesting the patients included within the study had contact with the virus “more than 3 weeks before admission”.

Pain, CHedrich, CLancet RheumatolNovel paediatric presentation of COVID-19 with ARDS and cytokine storm syndrome without respiratory symptoms15 May 2020United Kingdom Europe1Clinical - PIMS-TShttps://www.thelancet.com/action/showPdf?pii=S2665-9913%2820%2930137-5

This is a case report from Alder Hey Childrens Hospital, Liverpool of previously health 14 year old patient fitting criteria for PIM-TS, successfully treated with Anakinra.

Initial presentation : This patient initially presented with a a 3-day history of fever, abdominal pain, nausea, and vomiting, and no respiratory symptoms. A previous history of mild respiratory symptoms 3 weeks earlier was reported. On initial presentation patient had fever 38.1, was cardiovascularly stable, no respiratory distress, but had a tense abdomen with guarding in right upper and lower quadrant. Initial investigations conducted showed; bloods - lymphopenia (0·14 × 109 cells/L), CRP of 242mg/per L, urine – sterile pyuria (30cells), radiology – normal CXR, normal abdominal ultrasound. Nasopharyngeal Sars CoV2 PCR – sent (subsequently negative). A provisional diagnose of acute appendicitis was made, and patient started on Piperacillin-tazobactam.

Deterioration : Within 24 hours of admission, patient became visually more unwell, was tachycardic, had increased dyspnoea and cough, and developed a widespread maculopapular rash. Further investigations showed; Radiology – Ct chest, showed typical findings of SARS-CoV-2. Bloods showed; lymphopenia, anaemia, thrombocytopenia, raised CRP and Ferritin, raised serum interleukin (IL)-6 (1098 pg/mL [normal range<7]), coagulopathy with raised D Dimers and prolonged PR and APTT, raised increased liver enzymes, hypertriglyceridaemia, ANA negative, raised APL (anticardiolipin IgG 25·5 U/mL [normal range <20] and antiβ2-glycoprotein IgG 28·8 U/mL [normal range <20]) were positive, and low complement levels (C3 0·09 g/L [normal range 0·90–1·88], C4 0·12 g/L [normal range 0·18–0·42]). Patient also developed mild polyarticular arthritis.

Treatment and ongoing care : Initial oxygen requirement (8 L/min), finally escalating to CPAP ventilation support. IV Bolus for hypertension. Anti-inflammatory treatment with recombinant IL-1 receptor antagonist (Anakinra) was started after multidisciplinary discussion. It was commenced at 4 mg/kg per day s/c but increased to 8 mg/kg per day after 36 hours because patient required inotropic support for hypotension and rising lactate (6 mmol/L). Because of cardiovascular involvement (borderline LV systolic dysfunction, aortic regurgitation, progressive left coronary dilatation, enzyme leak with troponin-T 45 ng/L), aspirin was started (2 mg/kg) for its antithrombotic effects. Patient did not show additional clinical features of Kawasaki disease, and upon discussion IVIG nor corticosteroids were not given.

Outcome : SARS-CoV-2 IgG became positive (borderline day 6, positive day 11). In temporal relation with anakinra treatment, the patient’s respiratory status stabilised and clinical and laboratory variables returned to normal.

Cabrero-Hernandez, MSerrano-Gonzalez, APediatr Infect Dis JSevere SARS-CoV-2 Infection in Children With Suspected Acute Abdomen: A Case Series From a Tertiary Hospital in Spain10 May 2020SpainEurope5Clinical - PIMS-TShttps://journals.lww.com/pidj/Abstract/9000/Severe_SARS_CoV_2_Infection_in_Children_With.96141.aspx
Balasubramanian, SRamanan, AIndian PediatrHyper-inflammatory Syndrome in a Child With COVID-19 Treated Successfully With Intravenous Immunoglobulin and Tocilizumab10 May 2020IndiaAsia1Clinical - PIMS-TShttps://www.indianpediatrics.net/COVID29.03.2020/CCL-00180.pdf
Rivera-Figueroa, ESimpson. SIndian PediatrIncomplete Kawasaki Disease in a Child With Covid-199 May 2020USANorth America1Clinical - PIMS-TShttps://www.indianpediatrics.net/COVID29.03.2020/CCL-00179.pdf
Riphagen, STheocharis, PLancet Hyperinflammatory shock in children during COVID-19 pandemic1 May 2020LondonEurope8Clinical - PIMS-TShttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31094-1/fulltext

This is the first case series to describe a cluster of children presenting with hyperinflammatory shock during the COVID-19 pandemic.

Eight children aged 4 to 14 years were identified by a paediatric retrieval service based in London in mid-April 2020. Interestingly, of the 8 children, 7 had weights >75th centile. Notably 6 were of Afro-Caribbean descent and 2 were Asian, with no Caucasian children in this cohort. 5/8 were boys. 4 children had exposure to family members with COVID-19.

The clinical presentation was similar to Kawasaki disease, with unrelenting fever, rash, conjunctivitis, peripheral oedema, and extremity pain, in addition to gastrointestinal symptoms. All children developed warm, vasoplegic shock and required inotropic support. Seven children required mechanical ventilation.

Small pleural, pericardial and ascitic effusions, also consistent with a diffuse inflammatory process were also observed. Vascular involvement was demonstrated with echo-bright coronary arteries seen in all children, with a giant coronary aneurysm in one patient. One child died from a large cerebrovascular infarct. Myocardial enzymes were significantly elevated.

A range of investigations were done in all children, and despite this no causative pathogen was identified. Adenovirus and enterovirus were isolated in one child. Four children had known exposures to SARS-CoV-2 in family members, but only two tested positive for SARS-CoV-2 (1 was positive only postmortem).

In addition to other supportive therapies, all children received IVIG and broad-spectrum antibiotics (ceftriaxone, clindamycin). Six children have been given aspirin. This clinical presentation may represent a new phenomenon associated with SARS-CoV-2 infection in children and has remarkable similarities to Kawasaki Disease. Following publication of this case series, Evelina London Children’s Hospital has managed >20 similar cases in children. Ten of these children were SARS-CoV-2 antibody positive (unclear which antibody or which test was used).

These findings have garnered particular interest due to the fact that children have otherwise been relatively spared from severe disease due to COVID-19, and here both the temporal association and high proportion of children with seemingly positive serology suggests a possible association with this hyperinflammatory syndrome. Anecdotally, clusters have also been noted in the USA (particularly NYC) and some centres in Spain and Italy. Reports are conspicuously absent from Asia, most notable as Kawasakis disease is more common amongst this population normally. Even more striking is the gross overrepresention of children with an Afro-Carribean background, which given current investigations into the increased incidence of severe adult disease in these communities seems even more pertinent.

As so little is currently known about “garden variety” Kawasakis, it will make defining this disease and its associated with COVID-19 that bit more difficult, but studies are currently ongoing to assess the nature and mechanism of this disease (https://www.diamonds2020.eu/). For now, this cohort doesn’t change the management of childhood COVID-19, nor does it change the management of hyperinflammatory shock or Kawasakis – although the RCPCH have produced excellent guidance for suggested investigations and processes to include these patients in ongoing research.

Jones, VMathew, RHospital PediatricsCOVID-19 and Kawasaki Disease: Novel virus and novel case7 Apr 2020AmericaNorth America1Clinical - PIMS-TShttps://hosppeds.aappublications.org/content/hosppeds/early/2020/04/06/hpeds.2020-0123.full.pdf

This is a case study from the USA of a 6m old child who presented with fever and fussiness with no history of respiratory symptoms. They had unremarkable flu swab and urine MC&S, diagnosed viral illness. She subsequently developed an erythematous non-pruritic and blotchy rash.

On day 4 of fever she presented with the rash, still no significant respiratory symptoms. She was tachycardic, irritable, had limbic sparing conjunctivitis and dry cracked lips with no lymphadenopathy and no extremity skin changes. She had normal platelets with high CRP (133mg/L). Chest x-ray showed faint opacity in the left lung, and respiratory PC negative. No unwell contacts, no travel.

She was admitted with suspected Kawasakis, and due to fever and CXR was swabbed for SARS-CoV-2. Upon arrival to the paeds ward she met all Kawasakis criteria and was treated with IVIG and aspirin. Normal Echo. Just before discharge her SARS-CoV-2 test returned positive.This case is highly pertinent given current media headlines about a collection of cases in the UK of a Kawasaki like syndrome, some testing positive for COVID-19 and some negative. This case seems a bit different, as the child had “barn door” classic Kawasaki syndrome, and had an otherwise unremarkable course.

Further details regarding these cases from London (and possibly elsewhere) will be needed to determine a link between COVID-19 and a systemic inflammatory response syndrome. 3 things are particularly interesting.

Kawasakis disease has been theorised to be triggered by viral infections. One could imagine if this is the case, then COVID-19 could also trigger a similar syndromeIt is well documented that some adults experience a systemic inflammatory response to COVID-19 (including cytokine storm) and whilst children generally suffer a much milder course, it seems within reason that a subset of children may develop a similar illnessReports from a paper in 2005 suggested a link between human coronaviruses in Kawasakis disease. A case control study found significantly higher rates of coronavirus in children with Kawasakis (72.7%) than a matched control group without Kawasakis (4.2%) The meaning of all this is still unclear – it doesn’t change the management of Kawasakis disease or COVID-19, but presents interesting research questions which can be addressed in the coming months.

Sola, A MChan, D KJAMA PediatrPrevalence of SARS-CoV-2 Infection in Children Without Symptoms of Coronavirus Disease 201925 Aug 2020USNorth America33041Epidemiology - Disease Burdenhttps://jamanetwork.com/journals/jamapediatrics/fullarticle/2769878

An epidemiological study of asymptomatic Covid-19 in children across 28 centres in the US from 29/05/2020 to 09/07/2020. Asymptomatic children presenting to the ENT team (for surgery, clinic or planned admissions) were screened for Covid-19. It is noted that they may have had symptoms attributed to their underlying conditions that overlap with Covid-19 symptoms, but that there was not clinical suspicion of Covid-19.

Covid-19 weekly incidence data for the whole population was then obtained for the geographical areas of the hospitals from Johns Hopkins for the same time period and compared with the paediatric asymptomatic screening results.

Results: 250 of 33 041 children (age range, 0-18 years) without symptoms were positive for Covid-19 (on PCR testing). Prevalence varied from 0% to 2.2% between areas, with a pooled prevalence of 0.65% (95% CI, 0.47%-0.83%, with significant heterogeneity).

The whole population weekly Covid-19 incidence for each area was strongly correlated to the paediatric asymptomatic prevalence for that area.

Conclusions: Asymptomatic carriage of Covid-19 in children was found to be low but with significant heterogeneity of results according to centre. It was strongly correlated with the whole population incidence of Covid-19 in that area.

Wood, JJohn, CCureusPrevalence of Asymptomatic SARS-CoV-2 Infection in Children and Adults in Marion County, Indiana16 Aug 2020USANorth America119Epidemiology - Disease Burdenhttps://www.cureus.com/articles/35775-prevalence-of-asymptomatic-sars-cov-2-infection-in-children-and-adults-in-marion-county-indiana
Ladhani, SNRamsay, ME ADCCOVID-19 in children: analysis of the first pandemic peak in England12 Aug 2020UKEurope35200Epidemiology - Disease Burdenhttps://adc.bmj.com/content/early/2020/07/28/archdischild-2020-320042

Ladhani et al have provided epidemiological insight into COVID-19 between the dates of 16 January to 3 May 2020 in children compared to adults in England by reporting data from both Public Health England surveillance and Patient Demographic Service fatality data.

Their data adds to the growing evidence bank of the limited role played by children in the pandemic: only 1% of all cases of COVID-19 in England in the first four months of the pandemic were in the under 16 age group.

During the study period nearly half a million people in England were tested for SARS-CoV-2. Twenty-four percent of tests were positive but only 1.1% (1,408) of the positive cases were children.

35,200 children were swabbed, but only 4% were positive. The highest rates of SARS-CoV-2 were found in infants, particularly those under 3 months. This was a much lower percentage than adults who were swabbed, who tested positive in 19.1 – 34.9% of adults and older ages (the highest rates being in the over 80s).

When the data for people presenting in the community with an acute respiratory infection was analysed it demonstrated a very low percentage of children (only 2.8%) positive for SARS-CoV-2 contrasting with much higher rates in adults, reaching nearly 50% in the over 80s.

During the 3 and a half months of the study, 8 children with SARS-CoV-2 died (0.3%), 4 of whom had multiple comorbidities. The other 4 children died of other causes, with SARS-CoV-2 reported as an incidental or indirect contributor to death. Overall, despite fears that the national ‘Stay at Home’ message would lead to delayed presentations to emergency departments and potentially avoidable fatalities, there was no increase in excess deaths in children, even though excess deaths were reported in other age groups.

The findings from this study are consistent with data from other countries: children make up only a very small percentage of COVID-19, with a low case-fatality rate. Contrary to some assertions the data cannot inform us regarding children's involvement in transmission

Kim, LGarg, SMMWR Morb Mortal Wkly RepHospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 - COVID-NET, 14 States, March 1-July 25, 20207 Aug 2020USANorth America576Epidemiology - Disease Burdenhttps://www.cdc.gov/mmwr/volumes/69/wr/mm6932e3.htm

This report was posted as a Morbidity and Mortality Weekly Report Early Release on 7th August 2020 on the US Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/mmwr). Most COVID-19 cases in children under 18 years of age are asymptomatic or mild; here data is presented about more severe cases in children hospitalised with COVID-19 between 1st March and 25th July 2020 in 14 US states.

Background: The COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) is a population-based surveillance system which collects data on laboratory-confirmed COVID-19 hospitalisations in 99 counties of 14 states in the USA (California, Connecticut, Colorado, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, Utah) representing all 10 US Department of Health and Human Services Regions. COVID-NET surveillance includes COVID-19-associated hospitalisations among residents in a predefined surveillance catchment area who had a positive SARS-CoV-2 molecular test (ordered at the discretion of the treating health care provider) during hospitalisation or up to 14 days before admission. Trained surveillance officers perform medical chart abstractions for all identified cases.

Study design: 576 patients < 18 years of age hospitalised with COVID-19 were reported to COVID-NET from 1st March to 25th July 2020. 208/576 (36%) had complete medical chart reviews. This report is a descriptive analysis of the available data for these inpatients with a positive SARS-CoV-2 test up to 14 days before or during admission to hospital. Only those hospitalisations with complete medical chart review where patients were discharged alive or died during hospitalisation were included for clinical intervention, treatment and outcome figures. Weekly and cumulative COVID-19–associated hospitalisation rates were also calculated: numerator = number of catchment area residents hospitalised with COVID-19 / denominator = National Center for Health Statistics vintage 2019 bridged-race postcensal population estimates.

Age of children hospitalised with COVID-19: Median age was 8 years (IQR 9 months to 15 yrs). Breakdown: under 3 months: 108/576 (18.8%), 3-5 months 20/576 (3.5%), 6-11 months 29/576 (5.0%), 12-23 months 31/576 (5.4%), 2-4 yrs 50/576 (8.7%), 5-11 yrs 97/576 (16.8%), 12-17 yrs 241/597 (41.8%).

Gender of children hospitalised with COVID-19: Male 292/576 (50.7%), female 284/576 (49.3%). Breakdown by age: 0-2 yrs 56% male/44% female; 2-4 yrs 50% male/50% female; 5-17 yrs 48% male/52% female.

Race/ethnicity of children hospitalised with COVID-19: Information about race/ethnicity was reported for 526/576 (91.3%) patients. Hispanic/Latino 241/526 (45.8%), non-Hispanic black 156/526 (29.7%), non-Hispanic white 74/526 (14.1%), non-Hispanic Asian or Pacific Islander 24/526 (4.6%), non-Hispanic American Indian/Alaska Native 4/526 (0.8%), multiple races 3/526 (0.6%), unknown 24/526 (4.6%).

Underlying medical conditions in children hospitalised with COVID-19: Information about underlying medical conditions was available for 222/576 (38.5%) patients. One or more underlying medical conditions 94/222 (42.3%), obesity (defined as body mass index (kg/m2) 95th percentile for age and sex based on CDC growth charts among children aged 2 yrs; not evaluated for children < 2 yrs) 42/111 (37.8%), chronic lung disease 40/222 (18.0%) (including 30 asthma), prematurity (< 37 weeks, data collected only for children < 2 yrs) 10/65 (15.4%), neurologic disorder 31/222 (14.0%), immunocompromised 12/222 (5.4%), feeding tube dependent 12/222 (5.4%), chronic metabolic disease 10/222 (4.5%) (including 6 diabetes mellitus), blood disorders 8/222 (3.6%) (including 6 sickle cell disease), cardiovascular disease 7/222 (3.2%) (including 4 congenital heart disease).

Breakdown of underlying medical conditions by race/ethnicity: Hispanic/Latino 43/94 (45.7%), non-Hispanic Black 28/94 (29.8%), non-Hispanic White 14/94 (14.9%).

Signs and symptoms reported on admission to hospital: Fever/chills 121/224 (54.0%) (commonest in < 2 yrs 50/67 (74.6%)), inability to eat/poor feeding (data collected only in < 2 yrs) 22/67 (32.8%), nausea/vomiting 69/224 (30.8%), cough 66/224 (29.5%), nasal congestion/rhinorrhoea 53/224 (23.7%), shortness of breath/respiratory distress 50/224 (22.3%), abdominal pain 42/224 (18.8%), diarrhoea 27/224 (12.1%). Gastrointestinal symptoms were reported by 42% of hospitalised children overall.

Length of stay in hospital (N=208): Median duration of stay 2.5 days (IQR 1-5 days), similar for all age groups.

Chest radiograph findings (N=67): Infiltrate/consolidation 44/67 (65.7%), bronchopneumonia/pneumonia 14/67 (20.9%), pleural effusion 4/67 (6.0%).

Chest CT findings (N=14): Ground glass opacities 10/14 (71.4%), infiltrate/consolidation 7/14 (50.0%), bronchopneumonia/pneumonia 4/14 (28.6%), pleural effusion 3/14 (21.4%).

COVID-19 investigational treatments: Only 12/208 (5.8%) received these medications, all aged 5-17 yrs (treatment categories not mutually exclusive). Remdesivir 9/208 (4.3%), azithromycin 6/208 (2.9%), hydroxychloroquine 4/208 (1.9%), convalescent plasma 1/208 (0.5%), lopinavir-ritonavir 1/208 (0.5%).

Admission to ICU: 69/208 (33.2%) admitted to ICU. Median length of stay in ICU 2 days (IQR 1-5 days). Breakdown by age: 0-2 yrs 19/61 (31.1%)(median stay 1 day), 2-4 yrs 9/24 (37.5%) (median stay 2 days), 5-17 yrs 41/123 (33.3%) (median stay 3.5 days). The proportion of hospitalised children admitted to ICU (approx. 1 in 3) is similar to the proportion of hospitalised adults admitted to ICU (32.0%) reported to COVID-NET.

Interventions: The highest level of respiratory support needed for each case that required respiratory support were as follows: invasive mechanical ventilation 12/207 (5.8%), BIPAP/CPAP 8/207 (3.9%), high flow nasal cannula 5/207 (2.4%). Administered: systemic steroids 19/208 (9.1%), intravenous immunoglobulin 14/208 (6.7%), vasopressor 10/208 (4.8%). 2 hospitalised children received ECMO. None received renal replacement therapy. Invasive mechanical ventilation was more frequently required in adults (18.6%).

Multisystem inflammatory syndrome in children (MIS-C): From 18th June 2020 onwards, information enabling discharge diagnoses of MIS-C where relevant has been systematically collected by COVID-NET: 9/83 (10.8%) of children with completed medical chart reviews after this date received a diagnosis of MIS-C.

Outcomes in children hospitalised with COVID-19: 1/208 (0.5%) death in hospital (a child with multiple underlying conditions).

Cumulative rate of COVID-19-associated hospitalisation in children (< 18 yrs): 8.0 per 100,000 population from 1st March to 25th July 2020, with highest rate among children < 2 yrs (24.8 per 100,000). Breakdown by race/ethnicity: Hispanic/Latino 16.4 per 100,000; non-Hispanic black 10.5 per 100,000; non-Hispanic white 2.1 per 100,000 (compared to 164.5 per 100,000 among adults).

Limitations of report suggested by authors: Laboratory confirmation of COVID-19 is dependent on clinician-ordered SARS-CoV-2 testing and rates are likely to be underestimates. Hospitalisation rates are preliminary and may change as additional cases are identified during the surveillance period. Approximately 60% of paediatric hospitalisations reported to COVID-NET have not had a medical chart review and the sample may be biased. Data on MIS-C was not collected until 18th June. However, data from COVID-NET is more geographically and racially diverse than single-centre or state-based studies and this report provides useful information about children hospitalised with COVID-19 in the US. Obesity was the most prevalent underlying condition in children hospitalised with COVID-19 in this report and Hispanic/Latino and black children had higher rates of COVID-19-associated hospitalisation than white children.

Bellino, SPezzotti, PediatrCOVID-19 Disease Severity Risk Factors for Pediatric Patients in Italy14 Jul 2020ITALYEurope3836Epidemiology - Disease Burdenhttps://pediatrics.aappublications.org/content/early/2020/07/16/peds.2020-009399

This study used an Italian national case based surveillance system of SARS-CoV-2 infections from February 27th until May 8th 2020. It focuses on the 3,836 paediatric cases (which accounts for 1.8% of the 216,305 total infections).

Cases were divided in severity into asymptomatic, paucisymptomatic, mild (uncomplicated URTI without dyspnoea or abnormal imaging), severe (pneumonia, hypoxia, dyspnoea, tachypnoea requiring hospitalisation) and critical (requiring intensive care).

Rates of infection among children were highest in teenagers and reduced with younger age groups. Adolescents 13-17 years accounted for 40.1% of childhood cases, followed by 7-12 year olds (28.9%), 2-6 year olds (17.2%) and 0-1 (13.8%). Just over half of all cases were male (51.5%)

Of all childhood cases, 13.3% required hospitalisation, however almost half the cases were children under 6 years of age (children <1 year accounted for 36.6%, 2-6 years 12.9%). This was followed by adolescents (13-17yo, 8.9%) and finally 7-12 years olds (8.8%). Children were more likely to have more severe disease if they had pre-existing medical conditions (OR 2.8, 95% CI [1.74-4.48]).

ICU admission occurred in 3.5% of childhood cases, and the highest proportion were children 2-6 years of age (9.5%).  There were four deaths (0.1% of all paediatric cases) - all children who had significant pre-existing underlying medical conditions as follows:

- 5 year old girl who developed SARS-CoV-2 pneumonia on a background of type 2 mucolipidosis with hypertrophic cardiomyopathy, thickened mitral and aortic valves and sleep apnoea - 2 month old boy with William's Syndrome who could not be weaned off ECMO following cardiac surgery for stenosis  and hypoplasia of pulmonary artery and supravalvular aortic stenosis. - 6 month old infant (gender not specified) with an extra renal malignant rhabdoid tumour who developed febrile neutropenia and pneumonia - 6yo girl with heart failure post-operative for a mitral annuloplasty for severe mitral insufficiency and left ventricular dysfunction.

Median time from symptom onset to diagnosis ranged from 3 days in infants to 6 days in adolescents. Symptom onset to hospitalisation also increased with age, from 1 day in infants to 4 days in adolescents. Due to ongoing data collection in the study, only 38.6% of childhood cases had completed recovery, but from available data, there was a median of 29 days from symptom onset to recovery (IQR, 23-37).

The study also looked at paediatric cases within the time frames of the first month of the epidemic, three weeks post peak epidemic and the last three weeks of the study dates. Cases detected in the last period  had lower risk of disease severity (3.5% vs 5.4% in the first month) and a longer time between symptom onset and diagnosis (9 days compared to 3 and 5 days in the prior periods). This may reflects change in testing practices, health care burden and management of cases over time.

When examining the larger data set of 216,305 total infections in the groups of paediatric (<18 years), adult (18-64 years) and elderly (>65 years), children had lower rates of infection, hospitalisation, ICU admission and much fewer deaths.

Over half of paediatric cases (63.4%) were asymptomatic or paucosymptomatic compared to 44% and 27.3% of adults and elderly respectively.  During the study period, 13.3% of children were hospitalised compared to 28.3% of adults and 49.9% of elderly. Severe or critical cases occurred in 4.2% in children, 17.2% adults and 41.1% elderly. Mortality rates were much higher in elderly (25.8%) and adults (5.8%) groups compared to the 4 deaths (0.1% in the paediatric population.

Overall, children had lower rates of SARS-CoV-2 infection and severity than adults and elderly. Within the paediatric population, adolescents were most likely to be infected (40.1% of cases), however the proportion of hospitalisation was higher in infants under 1 year of age (36.6% of cases) and ICU admission was more common in children from 2-6 years of age (9.5% of cases). All four deaths occurred in children 6 years and under who had significant pre-existing medical conditions.

Pollan, MYotti, RLancetPrevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study6 Jul 2020spain Europe6527Epidemiology - Disease Burdenhttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31483-5/fulltext

Introduction; Spain was one of the countries in Europe hit hardest by the Covid 19 pandemic. These are the first wave results from the Seroepidemiological Survey of SARS-CoV-2 Virus Infection in Spain (Encuesta Seroepidemiológica de la Infección por el Virus SARS-CoV-2 en España; ENE-COVID). This is an epidemiological study with an aim to estimate the sero-prevalence of Sars Cov2 in Spain through symptom checking, point of care antibody testing, and serology.

Methods: 35 883 households across Spain were selected through stratified two stage sampling and invited to take part. This is the result of the first wave of sampling which was conducted from April 27 to May 11, 2020. Participants within selected households answered a questionnaire on history of symptoms compatible with COVID-19 and risk factors. “Asymptomatic” was no symptoms, “paucisymptomatic” (1–2 symptoms without anosmia or ageusia), and symptomatic (anosmia or ageusia, or at least three symptoms among fever; chills; severe tiredness; sore throat; cough; shortness of breath; headache; or nausea, vomiting, or diarrhoea). Participants were contacted by phone and then invited to go to local primary care centre for testing or have a home visit. All participants were offered point-of-care antibody test (Orient Gene Biotech COVID-19 IgG/IgM Rapid Test Cassette; Zhejiang Orient GeneBiotech, Zhejiang, China, SARS-CoV-2 spike protein) and, if agreed, donated a blood sample for additional testing with a chemiluminescent microparticle immunoassay (SARS-CoV-2 IgG for use with ARCHITECT; Abbott Laboratories, Abbott Park, IL, USA, SARS-CoV-2 nucleoprotein). Sensitivity of the test was deemed any test positive (point of care/ serum), with specificity both tests positive. Of note Spain was under lockdown at the time of this study.

Results: Of 95 699 eligible individuals, 66 805 study participants took part, with 61 075 receiving point of care testing and 51 958 the immunoassay. Overall seroprevalence was 5.0% (CI 4.7–5.4) by the point-of-care test and 4.6% (CI 4.3–5.0) by immunoassay. In 7 provinces in the central part of Spain, including Madrid, seroprevalence was greater than 10% by both methods. Seroprevalence was similar for females and males. Seroprevalence was lower in the oldest age groups (≥85 years) compared with other adults. With regards occupation it was highest in health-care workers, 10.2% (7.9 - 13) than in other occupations these results were supported by the immunoassay.

In those who reported a contact with a confirmed case, seroprevalence was greater in those who had a confirmed case in their household (range 31.4% to 37.4% between the two tests), in their workplace 9.9–10.6%, among their non-cohabitating family members and friends 13.2–13.7%, or among their caregivers and cleaning staff 12.4–13.5%

Symptoms: For both tests seroprevalence was highest in those with a confirmed Sars CoV2 PCR more than 14 days before testing (88·6–90·1%). Among those with a positive test, the proportion of individuals who reported anosmia or three or more symptoms compatible with COVID-19 was 49.1% for the point-of-care test and 54. 2% for the immunoassay. In 32.7% (CI 30.2–35.4) of point-of-care test and 28.5% (CI 25.6–31.6) participants were asymptomatic.

Results in children: 11,422 children (<19 years) had a point of care test, with 6,527 also having an immunoassay. The proportion of paediatric participants having serology was lower than that of adults, though not unsurprising given the need for extra phlebotomy. Overall seroprevalence for those < 19 years was 3·4% (2·9–3·9) for point of care testing, and 6527 3·8% (3·2–4·6) for immunoassay.

Looking at specific age ranges for point-of-care test seroprevalence was < 1 year, 1.1% (0.3–3.5): 1- 4 years 2.1 %(1.3–3.4); 5 – 9 years 3.1% (2.2–4.2); 10-14 years 4.0% (3.1–5.0); and 15 – 19 years, 3.7% (2.9–4.8). The same pattern but slightly higher percentages were seen with immunoassay <1 year 0.0% (0.0–11.9); 1- 5 years 3.5% (1.7–6.8): 5 – 9 years 3.6% (2.3–5.7); 10 – 14 years 4.1% (3.1–5.5); and 15 – 19 years 3.8 (2.8–5.0). This paper did not give data on symptoms separately in age groups.

Conclusion: Population seroprevalence is lower than expected in areas of high endemic SARS-CoV-2, and is lowest in children. Close contact with people, particularly in the same household increases viral transmission. Over 30% of those with seroprevalence were asymptomatic. This highlights the importance of rapid identification and isolation with those with confirmed SARS-CoV-2, however isolation and separation for other household members may not be realistic in poorer or urban areas.

Ooldali, NDanis, KLancet Child Adolescent HealthEmergence of Kawasaki Disease related to SARS-CoV-2 infection in an epicentre of the French COVID-19 epidemic:a time-series analysis2 Jul 2020FranceEurope10Epidemiology - Disease Burdenhttps://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30175-9/fulltext#seccestitle140

This study aimed to determine whether the COVID-19 epidemic was associated with an increase in Kawasaki Disease.

Between December 2005 and May 20th 2020, 230 children presenting to this tertiary Paediatric centre in Paris, France were diagnosed with Kawasaki Disease (KD), or incomplete KD, according to diagnostic criteria of American Heart Association. The quasi-Poisson model estimated the median number of KD cases as 1.2 per month but with 2 notable peaks of increased incidence: in December 2009 when there was Influenza A H1N1 epidemic and in April-May 2020. The latter increase in Kawasaki cases started 2 weeks after the peak of the COVID-19 epidemic in Paris.

During April-May 2020, 10 paediatric in-patients were diagnosed with Kawasaki Disease (6 complete) median age 11.8y, 6 males. Symptoms of SARS-CoV-2 are not reported. 8 had a positive SARS-CoV-2 Nasopharyngeal PCR and/or SARS-CoV-2 serology and/or contact with a case: 1 of the other 2, had exposure to a confirmed case. Median CRP 23.6 mg/dl, Lymphocytes 1042 x 109. Radiological findings are not given. 6 of these children were admitted to PICU but all survived.

This group of patients is compared with a cluster in Bergamo in March-April 2020 and to the cluster at this hospital in December 2009 and there were significant differences with the latter.

The authors comment that this study adds to the evidence that suggests viral respiratory infections, including SARS-CoV-2, could be triggers for Kawasaki Disease. It is not stated how many of the 10 children would also meet the criteria for diagnosis of Paediatric Multi-system Inflammatory Syndrome temporally associated with COVID-19 and so adds more to the literature on Kawasaki Disease than that on PIMS-TS.

Gampel, BRoberts, SSPediatr Blood CancerCOVID‐19 disease in New York City pediatric hematology and oncology patients26 Jun 2020USANorth America174Epidemiology - Disease Burdenhttps://onlinelibrary.wiley.com/doi/10.1002/pbc.28420

This retrospective observational study provides some insight into the impact of COVID-19 on haematology/oncology patients. There were some limitations in the data collection process as testing was performed for different reasons at the two different sites that are considered. However, we see that between 10/03/2020 - 06/04/2020, 19 out of 174 tested children (each of whom had underlying haematological/oncological disorder or were undergoing haematopoietic stem cell transplantation) tested positive for COVID-19. Of these, 11 required hospitalisation. Five required PICU and one sadly died.

Method of data collection: All patients 21 years old or younger who underwent clinical laboratory COVID‐19 testing at two New York haem/onc centres were included. All patients had underlying haematological/oncological disorder or were undergoing haematopoietic stem cell transplantation. Informed consent was waived.

The two centres tested differently: “MSK tested all symptomatic patients and screened all patients prior to admission, procedures requiring sedation, and planned myelosuppressive chemotherapy. NYP tested only those patients for whom a positive test would alter management, including those who were symptomatic, likely COVID‐19 exposed, or with planned disposition to a chronic care facility.”

Features specific to children:19 out of 174 tested positive. Of these: 68% had fever, 47% had cough and 37% had dyspnea. 11 patients required hospitalisation and 4 patients required supplemental oxygen. 2 patients required mechanical ventilation and a further 3 were also admitted to PICU (all male). 3 patients received ‘COVID-19-directed therapy’ (with hydroxychloroquine and azithromycin) 1 patient died (“a child with sickle cell disease without a significant history of prior complications. Although this patient demonstrated pulmonary disease, his death may have been preceded by an acute cardiac event. Autopsy was refused…”). The authors make note that 64% of COVID+ oncology patients experienced treatment delays, showing the harms to these patients may not come primarily from COVID-19 disease itself

Pagani, GGalli, MmedRxivSeroprevalence of SARS-CoV-2 IgG significantly varies with age: results from a mass population screening (SARS-2-SCREEN-CdA)24 Jun 2020ItalyEurope000Epidemiology - Disease Burdenhttps://www.medrxiv.org/content/10.1101/2020.06.24.20138875v1

In this brief report of a SARS-CoV-2 serosurvey from Castiglione D'Adda in Italy, the results of a logistic regression model based on the random sampling of 509 subjects from the region (total population 4550) following the peak of transmission in the region are detailed. Prior to this serosurvey testing was limited to severely symptomatic cases.

The exact number of children included is not provided but the age related prevalence was significantly lower in children - 9.1% (0-5yo), 10.1% (5-10yo), 11.2% (10-15yo), 12.5% (15-20yo) - compared with overall seroprevalence of 22.6%.

The methodological details are limited in this report but the data are consistent with serosurvey data from elsewehere in Europe suggesting that children are less susceptible to SARS-CoV-2 infection compared with adults. 

Rha, BLangley,GJ Pediatric Infect DisSARS-CoV-2 Infections in Children - Multi-Center Surveillance, United States, January-March 2020."18 Jun 2020USANorth America4Epidemiology - Disease Burdenhttps://academic.oup.com/jpids/advance-article/doi/10.1093/jpids/piaa075/5859277?searchresult=1
Hua, CFu, JJ Med VirolEpidemiological features and viral shedding in children with SARS-CoV-2 infection15 Jun 2020ChinaAsia43Epidemiology - Disease Burdenhttps://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.26180
Stringhini, SGuessous, IThe LancetSeroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study11 Jun 2020SwitzerlandEurope455Epidemiology - Disease Burdenhttps://doi.org/10.1016/S0140-6736(20)31304-0

Methods: This study takes a representative population sample from Geneva, Switzerland (already identified by a pre-existing health study) and invites them to attend blood tests looking for antibodies against the SARS-CoV-2 virus over time. The purpose is to monitor what proportion of the population are infected and see how it changes during the course of the pandemic (5 weeks in this study). Participants could only attend once, and were invited by email with a telephone follow up. The only exclusion criteria was living in a prison or care home. Antibodies were measured using a commercial assay (ELISA for S1 domain of spike protein IgG). They performed in house validation of the assay using a couple of techniques (the results of the immunofluorescence validation were factored in to the sensitivity analysis of the model used later in the study)

Analysis: The statistical analysis performed was a Bayesian regression which had a random effect for households and factored in age/sex as well as the test performance to extrapolate the sample results on to population estimates of seropositivity. They calculated the relative risk (RR) of age groups having been infected with age 20 – 49yrs as the reference group.

Results: 5492 people were invited and the final analysis included 2766 people (3426 of the rest were non-responders or awaiting an appointment). 455 children participated. Seropositivity in the population increased between weeks 1 and 2 (4.8% to 8.5%), with no statistically significant difference thereafter (final estimate 10.8%).

The most significant result is that of the children<10yrs in the study, only 1/115 children tested positive (although a further 8 had an equivocal result). This made the RR of infection for children <10yrs 0.32 (0.11 – 0.63) compared to adults aged 20 – 49yrs. There was no statistically significant difference between children aged 10 – 19 yrs (OR 0.86, 0.57–1.22). Another important factor was strong association between household contacts (unsurprisingly). This is important, as there were also lower rates of infection seen in the elderly (>65 yrs OR 0.5, 0.28–0.78) but only 3% of these participants had a positive household contact. Of the 123 children aged 5-9yrs, 17% of them had a positive household contact.

This study adds to a growing body of evidence that younger children (particularly those under 10yrs) may be less susceptible to acquiring infection than adults. The RR of 0.3 despite a relatively high proportion having positive household contacts is in contrast to the elderly, whose low infectivity rate may be explained by reduces exposure (additionally, a relatively high number of elderly will have been hospitalised or passed away from infection during the study, meaning they will not be counted in these statistics).

Considerations: Schools were closed for the duration of this study period which will have reduced community exposure of young children. In addition, almost all validation of antibody assays has been in adults so far. There were a notable number of equivocal results in the young children, but the significance of this is unclear. The results are however consistent with the largest seroprevalence study to date, from Spain.

Alvarez-Roman, MTJimenez-Yuste, VHaemophiliaREGISTRY OF PATIENTS WITH CONGENITAL BLEEDING AND COVID-19 IN MADRID10 Jun 2020SpainEurope84Epidemiology - Disease Burdenhttps://onlinelibrary.wiley.com/doi/epdf/10.1111/hae.14089
Belot, ALevy-Bruhl, DEurosurveillanceSARS-CoV-2-related paediatric inflammatory multisystem syndrome, an epidemiological study, France, 1 March to 17 May 20204 Jun 2020FranceEurope156Epidemiology - Disease Burdenhttps://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.22.2001010#t1

The first epidemiological surveillance study of SARS-CoV-2-related paediatric inflammatory multisystem syndrome (also known as PIMS-TS). Carried out in France (population: 67 million) this was a nationwide study through the French public health agency. 156 cases were reported between 1st March and 17th May 2020 through both prospective and retrospective case identification.

Case definition required one or more of the following symptoms: seritis (serositis), characteristics of macrophage activation syndrome (MAS), myocarditis and/or Kawasaki-like disease (KLD). Cases were divided according to associated Covid status into confirmed, probable or possible CoV and non-CoV. Comparison was undertaken between non-CoV PIMS and CoV PIMS.

Of note, this definition differs marginally from the UK RCPCH definition of PIMS-TS which is a child with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopaenia) and evidence of single or multi-organ dysfunction.

.Age distribution showed a median of 8 years and an interquartile range of 5–11 years. Peak incidence was week of 18th to 27th April, which was 4-5 weeks behind the peak of the Covid-19 epidemic in France.

95 of the 156 reported cases were confirmed or probable Covid, supporting a causal link between Covid-19 infection and PIMS.

CoV-PIMS cases (n=108) compared with non-CoV PIMS cases (n=48) had a higher median age (8 vs 3) and showed higher rates of myocarditis (70% vs 10%), macrophage-activation syndrome (23% vs 2%), seritis (22% vs 10%) and ITU admission (67% vs 8%). Rates of Kawasaki-like disease (KLD) were higher in the non-CoV group (81% vs 61%0) supporting the idea that these are ‘classic’ Kawasaki Disease presentations. In the CoV-PIMS groups 73% required vasopressors, 43% were ventilated and one child died.

This is the first epidemiological surveillance study of PIMS-TS indicating rates across a population. It supports a causal link with Covid following 4-5 weeks behind the clinical illness.

Jie QuanYuan LiClin Inect DisAge-dependent gender differences of COVID-19 in mainland China: comparative study30 May 2020ChinaAsia0Epidemiology - Disease Burdenhttps://doi.org/10.1093/cid/ciaa683
Choe, PKim, NKJIMSelecting coronavirus disease 2019 patients with negligible risk of progression: early experience from non-hospital isolation facility in Korea29 May 2020KoreaAsia0Epidemiology - Disease Burdenhttp://kjim.org/upload/kjim-2020-159.pdf
Bandi, SMahdavinia, MPediatr Allergy ImmunolAfrican American children are at higher risk for COVID-19 infection29 May 2020USANorth America474Epidemiology - Disease Burdenhttps://onlinelibrary.wiley.com/doi/abs/10.1111/pai.13298
Zheng, XChen, JJ. InfectionCo-infection of SARS-CoV-2 and Influenza virus in Early Stage of the COVID-19 Epidemic in Wuhan, China28 May 2020ChinaAsia1Epidemiology - Disease Burdenhttps://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.journalofinfection.com%2Farticle%2FS0163-4453(20)30319-4%2Fpdf&data=02%7C01%7Cdr98%40leicester.ac.uk%7C1a70a2a944e24723c11108d807052900%7Caebecd6a31d44b0195ce8274afe853d9%7C0%7C0%7C637267066036624572&sdata=sL1i5FVbIszDDJ6an2gzf9kXbJakQIakOv4kzeTtDSw%3D&reserved=0
Yang, LLei, YJ Clin VirolEpidemiological and clinical features of 200 hospitalized patients with corona virus disease 2019 outside Wuhan, China: A descriptive study26 May 2020ChinaAsia3Epidemiology - Disease Burdenhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250074/pdf/main.pdf
Phaksy, AGabbie, SEMAResponse to "SARS-CoV-2 Testing and Outcomes in the First 30 Days after the first case of COVID-19 at an Australian Children's Hospital23 May 2020UKEurope18Epidemiology - Disease Burdenhttps://onlinelibrary.wiley.com/doi/abs/10.1111/1742-6723.13560
Buonsenso, DValentini, PLancet Inf DisToward a clinically based classification of disease severity for paediatric COVID-1915 May 2020ItalyEurope0000Epidemiology - Disease Burdenhttps://doi.org/10.1016/S1473-3099(20)30396-0
de Lusignan, SHobs, FLancet Infect DisRisk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study15 May 2020UKEurope23Epidemiology - Disease Burdenhttps://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930371-6

This study examines the demographic and clinical risk factors for testing positive for SARS-CoV-2 amongst patients within a large primary care network in the UK. This included tests done through Public Health England and the UK National Health Service (NHS) between January 28th and April 4th 2020 with clinical and sociodemographic data extracted from patients' primary care medical records.

Overall 587 of 3802 patient tests returned a positive result for SARS-CoV-2. Of children 4.6% (23/499) tested positive compared with 17.1% (564/3303) of adults.

In multivariate logistic regression, adults had significantly higher odds of a positive test compared with children; those aged 40-64 (aOR 5.36, 95% CI 3.28-8.76) and >75 (aOR 5.23, 95% CI 3.00-9.09) were at highest risk.

Male sex (aOR 1.55, 95% CI 1.27-1.89), social deprivation (aOR 2.03, 95% CI 1.51-2.71) and black ethnicity (aOR 4.75, 95% CI 2.65-8.51) were also associated with an increased risk of a positive SARS-CoV -2 test. Of clinical factors, only chronic kidney disease (aOR 1.91, 95% CI 1.31-2.78) and obesity (aOR 1.41, 95% CI 1.04-1.91) were significantly associated with testing positive. Surprisingly active smoking was associated with lower odds of a positive test (aOR 0.49, 95% CI 0.34-0.71) possibly due to presentation confounding (i.e. presence of cough in chronic smokers prompting increased testing in this group).

This is the first study to utilise primary care data to assess risk factors for testing positive for SARS-CoV-2 in the community. The risk factors identified are similar to those associated with severe COVID-19 in hospitalised patients including increased age, male sex and obesity. The higher odds of a positive test in adults compared with children here are consistent with other studies suggesting children are at lower risk of SARS-CoV-2 infection compared with adults.

Deng, XYu, HClin Infect DisCase fatality risk of the first pandemic wave of novel coronavirus disease 2019 (COVID-19) in China15 May 2020ChinaAsia996Epidemiology - Disease Burdenhttps://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa578/5837356
COVID-19 National Incident Room Surveillance TeamCommun Dis IntellCOVID-19, Australia: Epidemiology Report 1515 May 2020AustraliaAustralasia172Epidemiology - Disease Burdenhttps://doi.org/10.33321/cdi.2020.44.43
Yanover, C.Mizrahi, B.Med archivesWhat factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization13 May 2020IsraelMiddle East647Epidemiology - Disease Burdenhttps://www.medrxiv.org/content/10.1101/2020.05.07.20091652v2.full.pdf+html
Talarico, VRaiola, GActa Biomed .Preliminary Epidemiological Analysis on Children and Adolescents With Novel Coronavirus Disease (2019-nCoV) in a Central Area of Calabria Region11 May 2020ItalyEurope173Epidemiology - Disease Burdenhttps://www.mattioli1885journals.com/index.php/actabiomedica/article/view/9550/8798
Das, AGopalan, SMedrxivEpidemiology of CoVID-19 and predictors of recovery in the Republic of Korea11 May 2020Republic of KoreaAsia202Epidemiology - Disease Burdenhttps://www.medrxiv.org/content/10.1101/2020.05.07.20094094v1.full.pdf+html
Garazzino, SItalian SITIP-SIP Paediatric Infection Study GroupEurosurveillanceMulticentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April 20207 May 2020ItalyEurope168Epidemiology - Disease Burdenhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219028/

This rapid communication reports the preliminary results of an Italian multicentre study involving 11 of 13 exclusively paediatric hospitals and 51 of 390 paediatric units across Italy (mainly in central and northern Italy). Retrospective data collection began on 25 March 2020.

Study design: Data to 10 April 2020 collected by participating physicians and hospitals for all paediatric patients (aged 1 day to 17 years) with at least one RT-PCR SARS-CoV-2 positive nasal/pharyngeal swab AND adequate follow-up considered necessary by the clinician to define the final outcome (usually 2 wks).

Findings: Data collected for 168 children and adolescents with documented COVID-19:

Gender: 94/168 male (55.9%) & 74/168 female (44.1%)

Age: median 2.3 yrs (IQR 0.3-9.6 yrs, range 1 day-17.7 yrs, mean 5 yrs. <1 yr: 66/168 (39.3%), of which 15/168 neonates (6.9%). 1-5 yrs: 38/168 (22.6%). 6-10 yrs: 24/168 (14.3%). 11-17 yrs: 40/168 (23.8%)

Hospitalised: 110/168 (65.1%): <1 yr: 52/66 (78.8%). 1-5 yrs: 24/38 (63.2%). 6-10 yrs: 13/24 (54.2%). 11-17 yrs: 21/40 (52.5%)

Comorbidities: 33/168 (19.6%): chronic lung disease 7, congenital malformations or complex genetic syndromes 14, cancer 4, epilepsy 5, gastrointestinal disorders 2, metabolic disorders 1,immunosuppression 4, immunocompromise 3. The hospitalisation rate was similar between children with comorbidities (23/33, 70%) and those without (87/135, 64%).

Source of infection: Close contact with a COVID-19 infected person outside the family was rarely reported. 113/168 (67.3%) of children had at least one parent who tested positive for SARS-CoV-2 infection. Symptom onset in relatives preceded symptoms in the infected child by 1 to 14 days in 88/113 (77.8%).

Symptoms: 4/168 (2.4%) asymptomatic. Fever (37.5 to 39C) 138/168 (82.1%), cough 82/168 (48.8%), rhinitis 45/168 (26.8%), diarrhoea 22/168 (13.1%), dyspnoea 16/168 (9.5%), pharyngitis 9/168 (5.4%), vomiting 9/168 (5.4%), conjunctivitis 6/168 (3.6%), chest pain 4/168 (2.4%), fatigue 3/168 (1.8%), non-febrile seizures 3/168 (1.8%, all 3 had a known history of epilepsy), febrile seizures 2/168 (1.2%, 1 with a history of febrile seizures and 1 with first episode of febrile seizures as onset of COVID-19).

Blood results: Of the children who had blood tests, 47/121 (38.8%) had CRP > 0.5 mg/dl. Other abnormal findings were rare.

Complications: 33/168 (19.6%) developed complications: interstitial pneumonia 26/168 (15.5%), severe acute respiratory illness 14/168 (8.3%), peripheral vasculitis 1/168 (0.6%)

No child underwent a chest CT scan; pneumonia was assessed using X-ray or ultrasound in 75/168. Co-infection: Documented in 10/168 (5.9%), including 3 RSV, 3 rhinovirus, 2 EBV, 1 influenza A, 1 non-SARS coronavirus infection, 1 Strep pneumoniae.

Treatment: 16/168 (9.5%) required non-invasive oxygen treatment. 2 were admitted to ICU for mechanical ventilation (1 preterm neonate and a 2-month-old with congenital heart disease). 49/168 (29.2%) children (those with more severe illness) received experimental SARS-CoV-2 treatments, including lopinavir/ritonavir, hydroxychloroquine and/or azithromycin/clarithromycin, systemic steroids.All children, including those with comorbidities, recovered fully and there were no sequelae reported at the time of submission. This paediatric data is in contrast to the high number of cases and case-fatality rate seen in adults in Italy. Children comprised a marginal percentage of those hospitalised in Italy with SARS-CoV-2 infection.

Lounis, MElectron J Gen MedA Descriptive Study of the Current Situation of COVID-19 in Algeria6 May 2020AlgeriaAfrica79Epidemiology - Disease Burdenhttps://www.ejgm.co.uk/download/a-descriptive-study-of-the-current-situation-of-covid-19-in-algeria-8287.pdf
Lian, JYang, YWileyEpidemiological, clinical, and virological characteristics of 465 hospitalized cases of coronavirus disease 2019 (COVID‐19) from Zhejiang province in China4 May 2020ChinaAsia3Epidemiology - Disease Burdenhttps://onlinelibrary.wiley.com/doi/10.1111/irv.12758
COVID-19 National Incident Room Surveillance TeamCommun Dis Intell COVID-19, Australia: Epidemiology Report 13 (Reporting Week to 23:59 AEST 26 April 2020)1 May 2020AustraliaInternationalEpidemiology - Disease Burdenhttps://www1.health.gov.au/internet/main/publishing.nsf/Content/1D03BCB527F40C8BCA258503000302EB/$File/epidemiology_report_13_reporting_week_ending_23_59_aest_26_april_2020.pdf
Li, HHe, YFront Med (Lausanne) 7: 190.Age-Dependent Risks of Incidence and Mortality of COVID-19 in Hubei Province and Other Parts of China30 Apr 2020ChinaAsia260Epidemiology - Disease Burdenhttps://www.frontiersin.org/articles/10.3389/fmed.2020.00190/full
Goldstein, ELipsitch, MEurosurveillanceTemporal rise in the proportion of younger adults and older adolescents among coronavirus disease (COVID-19) cases following the introduction of physical distancing measures, Germany, March to April 202030 Apr 2020GermanyEuropeEpidemiology - Disease Burdenhttps://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.17.2000596
Chen, PXu, YJournal of Formosan Medical AssociationEpidemiological and clinical characteristics of 136 cases of COVID-19 in main district of Chongqing29 Apr 2020ChinaAsia4Epidemiology - Disease Burdenhttps://www.sciencedirect.com/science/article/pii/S0929664620301558
Sun, YWang, FJournal of Autoimmunity Characteristics and prognostic factors of disease severity in patients with COVID-19: The Beijing experience24 Apr 2020China Asia3Epidemiology - Disease Burdenhttps://www.sciencedirect.com/science/article/pii/S0896841120300895
Nikpouraghdam, MBagheri, MJournal of Clinical VirologyEpidemiological characteristics of coronavirus disease 2019 (COVID-19) patients in iran: A single center study21 Apr 2020IranMiddle East10Epidemiology - Disease Burdenhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7172806/pdf/main.pdf
Wang, PChen, SInt. J. Infect. DisStatistical and network analysis of 1212 COVID-19 patients in Henan, China18 Apr 2020ChinaAsia31Epidemiology - Disease Burdenhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180361/pdf/main.pdf
Lavezzo, ECrisanti, AmedRXivSuppression of COVID-19 outbreak in the municipality of Vo, Italy 17 Apr 2020ItalyEurope468Epidemiology - Disease Burdenhttps://doi.org/10.1101/2020.04.17.20053157

This paper outlines the strategy of a small town in Italy which immediately shutdown for 14 days following their first death from COVID-19 on Feb 21st 2020. They subsequently screened 86% of the population for SARS-CoV-2 using nasopharyngeal swabs, then screened again 2 weeks later (71.5% of the population).

At the start of the lockdown 2.6% (95% CI 2.1 – 3.3%) of the population tested positive, but 0 of 217 children aged 0 – 10 tested positive (0%), and only 3/250 aged 11 – 20 (1.2%) tested positive. By the end of the lockdown, 0/157 (0%) children aged 0 – 10 tested positive, and 2/210 (1%) children aged 11- 20 tested positive. Many of the children aged 0 -10 lived with infected individuals. They also noted >40% of people who tested positive were asymptomatic. They note a significant number of infections appeared to have come from asymptomatic individuals during contact tracing. They also note these asymptomatic individuals never developed symptoms, and had similar viral loads to symptomatic patients (as determined by the cycle threshold from RT-PCR).

This study has relatively small numbers, but again appears to provide evidence for several important features of paediatric infection: primarily that children appear significantly less likely to become infected than adults. It presents evidence for asymptomatic transmission, and against the theory of viral load correlation with symptom burden.

Randhawa A KJerome K RJAMAChanges in SARS-CoV-2 Positivity Rate in Outpatients in Seattle and Washington State, March 1-April 16, 202015 Apr 2020USANorth America909Epidemiology - Disease Burdenhttps://jamanetwork.com/journals/jama/fullarticle/2766035
Gujski, MPinkas, JMed Sci MonitEpidemiological Analysis of the First 1389 Cases of COVID-19 in Poland: A Preliminary Report15 Apr 2020PolandEurope231Epidemiology - Disease Burdenhttps://www.medscimonit.com/download/index/idArt/924702
Gudbjartsson, FStefansson, KNEJMSpread of SARS-CoV-2 in the Icelandic Population14 Apr 2020IcelandEurope1412Epidemiology - Disease Burdenhttps://www.nejm.org/doi/full/10.1056/NEJMoa2006100

This study describes the entry and spread of SARS-CoV-2 through Iceland. Importantly, this is the first epidemiological report to include SARS-CoV-2 screening of the general population and likely represents the most complete national epidemiological data published to date.

Study design: This report includes all confirmed SARS-CoV-2 infections in Iceland identified through either: targeted testing (January 31st to March 31st 2020) – 9199 predominantly symptomatic patients with travel to a high risk country or contact with a confirmed case; population screening (March 13th to April 1st 2020) – 13080 volunteers screened from the general population (without high-risk travel or contact with a confirmed case). Most patients in the population screening cohort were asymptomatic, with a minority with predominantly mild URTI symptoms. A subsequent period of random population screening from April 1st-4th excluded children.

SARS-CoV-2 real-time PCR was performed on combined oropharyngeal and nasopharyngeal samples. All confirmed cases were isolated and close contacts placed in quarantine for 14 days.

Key paediatric findings - there is comparative data provided on the 1412 children <10 years of age tested: of 564 children <10 years old tested in the targeted testing cohort, 6.7% (38) were positive – compared with 13.7% of persons >10 years old; of 848 children <10 years old tested in the population screening cohort, 0% (0) were positive – compared with 0.8% of persons >10 years old.

Details on severity of infection, hospitalisation rates and age specific symptom profiles are not included.

Discussion: The first SARS-CoV-2 infection in Iceland was confirmed on 28th February 2020. The dynamics of new cases has transitioned from imported infections initially to ongoing community spread. To date just over 0.5% of the population have had confirmed infection. Whilst physical distancing measures have been put into place including limiting gatherings to a maximum of 20 people, elementary schools have remained open. Iceland has amongst the highest national rates of SARS-CoV-2 testing per capita, with 6% of the population tested as described here. As a result this report provides the most accurate and complete national epidemiological data published to date.

The lower rate of positive tests in childen <10 year olds adds support the hypothesis that children are less susceptible to SARS-CoV-2 infection compared to adults. Similarly the lack of positive tests amongst >800 children screened goes against the theory that the low reported rates of COVID-19 in children are due to a large number of undocumented/asymptomatic paediatric cases. This finding, particularly, has important implications in decision-making around patient flow and isolation in general paediatric care, suggesting that routine testing and isolation of asymptomatic children may be of low yield in similar settings. Clearly a single PCR screening test at one time point has an insufficient negative predictive value to exclude infection. As such, serological studies will be important in providing a clearer picture of the extent of SARS-CoV-2 infection in children.

Conclusion: Children under 10 yo appear to be less likely to develop SARSCoV-2 infection compared with people >10 yo. In settings with moderate levels of SARS-CoV-2 infection (0.5% population with confirmed infection in this setting), screening of asymptomatic children without overseas travel or contact with a known case is of very low yield.

Amira, YWakita, TEmerg Infect DisSevere Acute Respiratory Syndrome Coronavirus 2 Infection among Returnees to Japan from Wuhan, China, 202010 Apr 2020JapanAsia10Epidemiology - Disease Burdenhttps://wwwnc.cdc.gov/eid/article/26/7/20-0994_article
Santacroce, LDel Prete, REJGMCOVID-19 in Italy: An Overview from the First Case to Date8 Apr 2020ItalyEurope1Epidemiology - Disease Burdenhttps://www.ejgm.co.uk/article/covid-19-in-italy-an-overview-from-the-first-case-to-date-7926
Tagarro, AJAMA PedScreening and Severity of Coronavirus Disease 2019 (COVID-19) in Children in Madrid, Spain8 Apr 2020SpainEurope365Epidemiology - Disease Burdenhttps://jamanetwork.com/journals/jamapediatrics/fullarticle/2764394

This is a registry of confirmed COVID-19 cases in Madrid, Spain from March 2 to March 16 – the first 2 weeks of the epidemic in Spain. Children were screened according to recommendations at the time with PCR.

Of 365 children tested, 41 were positive (11.2%), out of the 4695 cases in the Madrid region (0.8%). 16 children (39%) with confirmed COVID had a known contact with a confirmed case. The median age of positive cases was 1 years. 60% required hospitalisation, 9.7% required PICU admission, and 9.7% required respiratory support beyond nasal prongs (including both non-invasive and invasive mechanical ventilation). Of those requiring ICU admission, only 1 (25%) had a comorbidity (recurrent wheeze). There were no deaths. Two patients (5%) had co-infection with influenza B, but it was not clear whether all patients were tested for co-infection.

CDCMMRWCoronavirus Disease 2019 in Children — United States, February 12–April 2, 20206 Apr 2020USANorth America2572Epidemiology - Disease Burdenhttp://dx.doi.org/10.15585/mmwr.mm6914e4

This is the first USA CDC report of COVID-19 looking specifically at children, examining confirmed cases nationally between FEbruary 12th and April 2nd. Due to the extremely disparate nature of public health reporting in the USA, the data quality and availability for this report is highly variable. There is no information as to the basis on which tests were performed, whether for presentation to hospital, symptomology or due to contact tracing. This cohort is therefore likely extremely heterogeneous. Of the nearly 150,000 confirmed cases in the US at this time, 2,572 (1.7%) were in children. New York City had 33% of paediatric cases. The median age was 11y and males account for 57%. Nearly 33% of cases were in children aged 15 – 17yrs, 15% in children <1y, 11% in children ages 1 – 4y and 15% in children 5 – 9y. 91% of cases had xposure to a known COVID-19 case.

Data on signs/symptoms was only available for 11% of cases. Fever, cough OR shortness of breath were present in 73% of cases, with fever in 56%, cough in 54%, shortness of breath in 13%, rhinorrhoea 7.2%, sore throat 24%, vomiting 11% and diarrhoea 13%. They have not reported on “asymptomatic” cases due to incomplete reporting on symptoms.CU admission was documented for 2% of cases. Hospitalisation was most common in infants (62%), with little difference between other age groups in regards to hospitalisation or ICU admission. From low numbers infants id not appear significantly more likely to be admitted to ICU. Underlying conditions were present in 23% of cases, most commonly respiratory (such as asthma), followed by cardiac conditions and immunosuppression. There are 3 deaths reported, but review is ongoing to determine whether COVID-19 was the cause. This patchy data from the US is useful as it closely resembles data from Chinese cohorts of children in regards to low frequency of severity and adverse outcomes. It confirms available data suggesting lower frequency of common symptoms in children as compared to adults.

Bialek, SSauber-Schatz, ECDC + Morb Mortal Wkly RepSevere Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 202018 Mar 2020USAAmerica123Epidemiology - Disease Burdenhttps://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm?s_cid=mm6912e2_w

Epidemiologic study of reported COVID–19 cases, by age group published by the United States’s CDC for the period, February 12–March 16, 2020. Data includes hospitalization, intensive care unit (ICU) admission, and case–fatality percentages by age, for 2449 patients with confirmed COVID-19 PCR, including 123 cases aged <19 year old. Of which, 1.6-2.5% hospitalisation rate, no ICU admissions, no deaths.

LivingstonBucherLancetCoronavirus Disease 2019 (COVID-19) in Italy17 Mar 2020ItalyEurope250Epidemiology - Disease Burdenhttps://jamanetwork.com/journals/jama/fullarticle/2763401

This is a helpful one page summary of data around COVID-19 numbers in Italy as of 15th March 2020.

Of note, there have been 22,512 cases of COVID-19 with 2026 (9%) being health care workers. There have been 1625 deaths (7.2%) of cases in Italy, which is a higher case fatality than rates from China and other countries so far. Below are two of the charts below which depict the age range and severity of COVID-19 infections. From a paediatric perspective, 1.2% of cases have been in patients <18 years old and remarkably there have been 0 deaths under 30yrs of age so far.

Choe, YMedRxIVCoronavirus disease-19: The First 7,755 Cases in the Republic of Korea15 Mar 2020South KoreaAsia480Epidemiology - Disease Burdenhttps://doi.org/10.1101/2020.03.15.20036368

This is a report of the first 7755 patients with confirmed COVID-19 in Korea as of March 13th. It is notable as Korea undertook one of the worlds most intensive strategies to community testing, which may give a better understanding of the proportions of different groups affected who may have had mild or subclinical infection and might otherwise not have been tested.

The finding of significance is that children made up a very small proportion of total cases, with only 75 (1%) under 9 years of age, and 405 (5.2%) aged 10–19 years. There were no deaths in patients under 30 years of age. This suggests not just low severity of infection in children, but a low attack rate with such low cases numbers.

Dong, YTong, SPediatricsEpidemiology of COVID-19 Among Children in China1 Mar 2020ChinaAsia2135Epidemiology - Disease Burdenhttps://pediatrics.aappublications.org/content/early/2020/03/16/peds.2020-0702
Wu, ZMcGoogan, JJAMACharacteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China; Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention24 Feb 2020ChinaAsia1400Epidemiology - Disease Burdenhttps://jamanetwork.com/journals/jama/fullarticle/2762130

A cornerstone paper outlining the initial epidemiological data from the outbreak (up to February 11th 2020). This paper gave us the first indication of the enormous impact of age on prognosis from the disease. It reports on 72,312 cases (44,672 confirmed and 16,186 suspected). Of these only 1% were aged <9 years (2% <19 years) with no deaths aged under 9 years.

Link-Gelles, RBandy, UMMWRSecondary Transmission of SARS-CoV-2 in Child Care Programs — Rhode Island, June 1–July 31, 202028 Aug 2020USANorth America18945Epidemiology - Transmissionhttps://www.cdc.gov/mmwr/volumes/69/wr/mm6934e2.htm

Following the reopening of state childcare programs with enhanced hygiene regulations in Rhode Island, USA, cases were examined for evidence of any transmission in the childcare setting, between 01/06/20-31/07/20. Of the 52 cases who were positive on testing or judged to be ‘probable’ in the absence of a test, 30 were children (median age 5 years) and 22 were adults (20 staff and 2 parents). Cases were found in 29/666 of the reopened programs. 20 had a single case with no evidence of any onward transmission. 5 programs had between 2-5 cases but without evidence of onward transmission. In the remaining 4 programs, onward transmission could not be ruled out. 10 cases occurred in one program which was found not to have been adhering to the enhanced state hygiene regulations.

This review highlights that in an area with relatively low levels of community transmission, basic infection prevention measures were effective and no significant transmission events were observed in childcare settings.

Hao LeiYuelong ShuJ InfectionHousehold transmission of COVID-19-a systematic review and meta-analysis25 Aug 2020chinaEverywhere2500Epidemiology - Transmissionhttps://doi.org/10.1016/j.jinf.2020.08.033

Normally systematic reviews and meta-analyses are done only after research studies have accumulated over a long period of time. However with COVID-19, as in so many ways, the whole process has been accelerated. This brief review attempts to summarise the published evidence around rates of household transmission of the SARS-CoV2 virus from studies conducted in January-March 2020. Their search came up with 24 papers reporting 18 studies from China, 2 from South Korea, 2 from USA and 1 each from Taiwan and Germany. Only one study was prospective: the others were case ascertainment (13), or retrospective cohort studies (10).

The key outcome meta-analysed was the household secondary attack rate (SAR), i.e. the number of identified cases divided by the number of household contacts. They found huge variations in SAR, ranging from 4.6% to 90%. This did not seem to depend on location. This degree of heterogeneity would suggest that the studies were very different in their methods and outcome measures. The pooled SAR was estimated at 27% (95% CI 21-32).

Some studies compared at-home and outside-home contacts, and found consistently, but not surprisingly, that home contacts were much more likely to transmit the virus: about 10 times the risk (OR 10.7; 95% CI 5.7-20.2).

More relevant to paediatricians, from the 8 studies where ages were reported, they found that adults were about 4 times more likely to become infected from household contacts than children (OR 3.7; 95% CI 2.8-4.9).

There is so much data missing from this meta-analysis that any conclusions must be guarded. Case definitions, testing accuracy, confidence that infection was acquired within the home rather than externally, and population demographics, will all have varied. There is also no distinction made between family households, and adult house-sharers: this may be particularly relevant as students return to universities.

Ismail, SLadhani, SmedRxivSARS-CoV-2 infection and transmission in educational settings: cross-sectional analysis of clusters and outbreaks in England24 Aug 2020EnglandEurope70Epidemiology - Transmissionhttps://www.medrxiv.org/content/10.1101/2020.08.21.20178574v1

This article is a preprint so should be interpreted with caution pending peer review This study, posted on medRxiv on 24th August 2020, uses Public Health England national surveillance data about COVID-19-related situations in educational settings across England gathered during the month of June, following the partial re-opening of schools in England from 1st June 2020, with follow-up until 31st July 2020.

Background: Schools across England were closed from 20th March 2020 because of rising COVID-19 cases. Vulnerable children and those with keyworker parents were able to continue attending school throughout the remainder of the spring term and the summer term. As part of gradual easing of lockdown measures, there was a partial re-opening of early years settings and primary schools from 1st June 2020, with children attending early years settings (nurseries and preschools for < 5 yr olds) and selected years in primary schools (reception (age 4-5 yrs), year 1 (age 5-6 yrs) and year 6 (age 10-11yrs)) allowed to return to school with strict infection control measures (including smaller classes separated into social bubbles (groups of staff and pupils who perform all activities together and don’t mix with other bubbles), social distancing and hand hygiene). This was followed on 15th June by the partial return to school of year 10 (age 14-15 yrs) and year 12 (age 16-17 yrs) in secondary schools, sixth forms and further education colleges. Attendance was not mandatory, not all schools re-opened and many eligible children did not return to school during the remainder of the summer term (June to mid-July 2020). In particular, attendance of older children in years 10 and 12 was much lower than in early years settings and primary schools.

Data collection: Public Health England (PHE) is responsible for the surveillance and public health management of COVID-19 in the community in England, including within educational settings. Suspected or confirmed cases of COVID-19 must be reported by institutions to their local PHE Health Protection Team (HPT), which performs a risk assessment for each event and decides on necessary investigations and measures. All events are recorded on HPZone, a national online database used to record health protection-related events requiring public health management, and reviewed daily at a national level. Missing information is obtained from outbreak reports or directly from the local HPT or educational setting. All COVID-19 situations reported to HPTs during the month of June 2020 were followed up for at least 14 days after the educational settings closed for the summer term. Educational settings include nurseries, preschools, infant schools, junior schools, primary schools, secondary schools, further education colleges, and settings catering to children of mixed age groups, or those of any age with special educational needs and/or disabilities (SEND).

Definitions: A case of COVID-19 was confirmed by a verifiable positive SARS-CoV-2 PCR from an upper respiratory tract sample. Cases were classified into 3 types:single confirmed cases, co-primary cases (2 or more confirmed cases with a common epidemiological link who were diagnosed at the same time – often asymptomatic siblings diagnosed during contract tracing after a positive result in a parent), outbreaks (2 or more epidemiologically linked cases where sequential cases were diagnosed within a 14 day period)

Educational settings were categorised into 3 groups: early years, primary schools (reception, year 1 and year 6 only) and secondary schools (years 10 and 12 only).

SARS-CoV-2 infections in educational settings in England: PHE received 170 reports of COVID-19-related events in educational settings in England from 1st to 30th June 2020. Public health investigations identified SARS-CoV-2 infections in only 101/170 (59%) of these events.

Breakdown of these 101 confirmed events:

Single confirmed cases: 67 events/101 (66%) involving 30/67 (45%) children and 37/67 (55%) staff members

Co-primary cases: 4 events/101 (4%) involving 10 children (0 staff)

Confirmed outbreaks: 30 events/101 (30%) involving 121 cases with 30/121 (25%) in children and 91/121 (75%) in staff

Total 198 confirmed cases: 70/198 (35%) in children, 128 (65%) in staff

Single confirmed cases: Occurred mainly in primary schools with 45/67 events (67%) (21 cases in children, 24 cases in staff) and early years settings with 10/67 (15%) (5 cases in children, 5 cases in staff). Secondary schools had 4/67 events (6%) (2 cases in children, 2 cases in staff). Other settings (mixed age groups, SEND, colleges) had 8/67 events (12%) (2 cases in children, 6 cases in staff).

Co-primary cases: In the 4 co-primary events involving 10 children, the co-primary cases lived in the same household. All 10 children were asymptomatic and had been tested because they were household contacts of an index case (a parent in 4/5 households).

Confirmed outbreaks: Primary schools 18/30 events (60%), early years 7/30 (23%), secondary schools 2/30 (7%), SEND schools 3/30 (10%). Affected contact bubbles were excluded in all 30 outbreaks and 13 settings also decided to close on an interim basis or for the rest of term.

Primary school outbreaks: 9/18 (50%) outbreaks involved staff only (affecting 32 people), of which 5/9 events had only 2 confirmed cases. The other 4/9 events had 4, 5, 6 and 7 confirmed cases. In 3 of these latter events the source was not identified, but the outbreak was propagated through contact between administrative and teaching staff in the school. Contact tracing in the final latter event was unusual in that 3/4 positive staff had probably acquired their infections separately from household members with confirmed COVID-19. 7/18 (39%) outbreaks involved staff and students, with a student the most likely index case in 6/7. In 5/7 of these the child index case was identified through testing of the whole household when parents (healthcare workers in 3 cases) had tested positive for SARS-CoV-2. The 7th outbreak involving staff and students was likely staff to pupil. The final 2/18 primary school outbreaks involved possible transmission between 2 children only, although acquisition in the household or community could not be ruled out.

Early years settings outbreaks: A staff member was the index case in all 7/7 (100%) outbreaks. 2/7 outbreaks involved only staff (2 and 12 confirmed cases, the latter following community exposure linked to a religious festival), 5/7 outbreaks involved staff transmission to small groups of children (maximum 4).

Secondary school outbreaks: Only 2 events involving only staff, with 2 confirmed staff cases each.

SEND settings outbreaks: 3 events with 2/3 involving staff only (6 and 2 confirmed staff cases), 1/3 with staff to child transmission (7 staff members positive with 1 child infected, at which point wider testing was carried out).

Source of infection: Single confirmed cases: not systematically collected.

Co-primary events: 10 children acquired infection from a household member.

Confirmed outbreaks: staff-to-staff 15/30 (50%), staff-to-student 7/30 (23%), student-to-staff 6/30 (20%), student-to-student 2/30 (7%). The likely source of infection identified in 27/30 children involved in an outbreak was a household contact in 8/27 (30%), school staff member in 17/27 (63%) and another student in 2/27 (7%). The likely source of infection identified in 61/91 staff members involved in an outbreak was a household contact in 9/61 (15%, these staff members were all likely index cases in the educational setting), 46/61 (75%) from another staff member and 6/61 (10%) from a student.

Number of secondary cases per index case in 30 confirmed outbreaks: For staff members as index case: only 1 secondary case in 11 outbreaks, between 2 and 9 secondary cases in 11 other outbreaks. For child as index case: only 1 secondary case in 5 outbreaks, 2 secondary cases in 3 outbreaks.

Correlation with regional COVID-19 incidence: There was a strong correlation between number of outbreaks in educational settings in June 2020 and regional COVID-19 incidence (0.51 outbreaks for each SARS-CoV-2 infection per 100,000 in the community, p=0.001). There was no correlation between single cases and regional incidence, nor between single cases or outbreaks and regional population size. National daily reports of positive SARS-CoV-2 PCR results collated by PHE for COVID-19 surveillance were used to calculate average weekly regional prevalence of infection.

Limitations identified by authors: Generalisation of these findings need to take into account the fact that educational settings started opening in England when SARS-CoV-2 incidence was low and only in regions with low community transmission. Stringent infection control measures were in place and only 1.6 million of 8.9 million students nationally attended any educational setting during this period. In particular, attendance by secondary school students was very low and these findings are unlikely to be generalisable to the full opening of secondary schools. Only a few settings were selected for wider testing.

Conclusion: SARS-CoV-2 infections and outbreaks were uncommon across all educational settings in England during June 2020. Outbreaks were usually small in size and 53% involved only one secondary case linked to the index case. Where the index case was a child, the maximum number of secondary cases was 2 (compared with 9 for staff members). Staff members had an increased risk of infection compared to students in any educational setting and the majority of cases linked to outbreaks were in staff.

Hurst, JKelly, MmedrxivSARS-CoV-2 Infections Among Children in the Biospecimens from Respiratory Virus-Exposed Kids (BRAVE Kids) Study21 Aug 2020USANorth America382Epidemiology - Transmissionhttps://www.medrxiv.org/content/10.1101/2020.08.18.20166835v1

In this prospective clinical and epidemiological study from Duke University Health System (DUHS), USA, risk factors, clinical manifestations and nasopharyngeal viral loads of a cohort of non-hospitalised children (<21 years old) with confirmed SARS-CoV-2 infection were documented. Cases were identified between April 7th and July 16th either through clinical presentation to DUHS or contact tracing of children with close contact with a confirmed case.

A total of 382 children were included; median age 9.7 years (IQR 4.8-15.9; 81% were of hispanic ethnicity. The majority (286/382 - 75%) received clinical testing for SARS-CoV-2 infection, whilst the remainder were tested specifically as part of the study. Overall 57% had a parent with SARS-CoV-2, 25% a sibling and 27% an "other" contact. 

In total 293 (77%) had confirmed SARS-CoV-2 infection. Infected children were more likely to be of Hispanic ethnicity (88% vs 57%) and have a co-infected sibling (49% vs 29%) than non-infected children. Asthma was less common amongst SARS-CoV-2 infected children (6% vs 17%). Of children with an infected sibling 46/145 (32%) did not have an identified adult close contact with SARS-CoV-2; median age amongst these 46 children was 12 (IQR 8.2-16.2).

The most common symptoms were fever (42%), cough (34%) and headache (26%). Asymptomatic cases accounted for 30% of confirmed infections; with a higher proportion asymptomatic amongst those 6-13 y.o. (39%), compared to 0-5 y.o. (25%) and 14-20 y.o. (24%). Children 0-5 y.o. and those 6-13 y.o. had significantly shorter duration of illness compared to adolescents (median 4 vs 7 days). Only one infant required hospitalisation. SARS-CoV-2 virals loads did not vary between age groups and there was no association between viral load and presence of symptoms. Viral loads were highest in the 3 days prior to symptom onset and declined thereafter.

This study represents one of the largest clinical and epidemiological studies of non-hospitalised children with SARS-CoV-2 infection. The findings of mild illness children with SARS-CoV-2 infection here is similar to previous reports. In addition this data suggest a shorter duration of illness in children 0-13 y.o. compared with older children. Secondary attack rates could not be calculated as case identification was not exclusively by prospective contact tracing. Furthermore, it was not possible to determine direction of transmission within households, although some cases of sibling to sibling transmission amongst the 46 cases without a close adult contact is plausible; notably these children were older compared to the overall study population. Similar to adult data, viral load was found to peak in the pre-symptomatic phase

Buonsenso, DSali, MmedRxiv preprintSeroprevalence of anti-SARS-CoV-2 IgG antibodies in children with household exposition to adults with COVID-19: preliminary findings12 Aug 2020ItalyEurope53Epidemiology - Transmissionhttps://doi.org/10.1101/2020.08.10.20169912

This article is a preprint so should be interpreted with caution pending peer review

This is a study of the prevalence of anti-SARS-CoV-2 IgG in children with household exposure to SARS-CoV-2, compared to adults exposed to the same index cases. It is a pre-print of a short report, containing only a summary of the data from an on-going study. The authors state that all data are available upon request.

Analysis; From a cohort of 405 adults diagnosed with COVID-19 as outpatients, 33 were identified as living with children younger than 18 years of age; 30 of these agreed to participate in the study. They had a total of 80 same-household contacts of whom 53 were children and 27 adults.

A total of 44 of the 80 same-household contacts (55%) had anti SARS-CoV-2 IgG. 16/27 (59%) adults and 28/53 (53%) children were seropositive (P > 0.05). Similar relative frequencies of seropositivity where present in children more than 5 years of age (21/39, 54%) and those less than 5 years (7/14, 50%) (P > 0.05).

10/28 children (35.7%) and 5/16 adults (33.3%) adults with anti SARS-CoV-2 IgG had previously been diagnosed with COVID-19.

Conclusions; The authors conclude that household transmission of SARS-CoV-2 is high in both adults and children, with similar rates of SARS-CoV-2 IgG in all age groups, including younger children. They claim that the real burden of the SARS-CoV-2 pandemic in children is underestimated.

Teherani, MJaggi, PJ PEDIAT INF DIS SOCBurden of illness in households with SARS-CoV-2 infected children11 Aug 2020USANorth America32Epidemiology - Transmissionhttps://academic.oup.com/jpids/advance-article/doi/10.1093/jpids/piaa097/5891283?rss=1

In this study from Atlanta, USA, household transmission was assessed in symptomatic children with laboratory-confirmed SARS-CoV-2 infection diagnosed from March 16th to June 14th 2020. 

Household contacts were identified by interviewing the patient's parents including: - the presence, absence and timing of symptoms consistent with COVID-19 in all household members, 

- any other household members with laboratory-confirmed SARS-CoV-2 infection and the likely household index case (the first household member to develop symptoms or test positive)

Of 138 children diagnosed, 32 (23%) families who were contactable and consented to interview were included.

Of the 32 cases:

- median age was 12.7 (IQR 8.3-15.7)  - 15 were hospitalised for a median of 3 days (IQR 2-13); 17 were discharged from ED

Of the 144 identified household contacts: - 58 were children, 86 were adults - only 29 (20%) were reported to have had SARS-CoV-2 testing - 67 (46.5%) developed symptoms consistent with COVID-19 including: 31 (21.5%) after the identified paediatric case 36 (25%) before the identified paediatric case

In 7/32 (22%) the identified paediatric case was determined to be the household index case (the first to develop symptoms) with suspected transmission to one or more adult household contacts. 

This study has several notable limitations including: - the small cohort size and the low response rate to interview.  - the reliance on parental recall of symptoms to determine transmission direction - the lack of systemic measurement or reporting of proportion of contacts with laboratory-confirmed SARS-CoV-2 infection  - the possibility of exposures outside of the household - over half of adult household contacts identified were essential workers, including 14 households with potential occupational exposure to SARS-CoV-2 identified.

As a result of these limitations it is difficult to draw broad conclusions from this study. It is clear that transmission from children infected with SARS-CoV-2 to others can occur, the frequency of this transmission and the relative contribution to disease transmission overall remains poorly defined. 

Maltezou, HPape, AJ. Med. VirolTransmission dynamics of SARS‐CoV‐2 within families with children in Greece: a study of 23 clusters7 Aug 2020GreeceEurope43Epidemiology - Transmissionhttps://onlinelibrary.wiley.com/doi/10.1002/jmv.26394

A study of Covid-19 transmission dynamics among 23 household clusters in Greece, identified through a national registry. Diagnosis of Covid-19 was made by PCR testing of respiratory samples with viral load classified as low, medium or high.

Study period: 26/02/2020 to 03/05/2020

Participants: 109 household members (66 adults and 43 children).

Results: The median attack rate per cluster was 60% (range: 33.4%‐100%). An adult member with COVID‐19 was the first case in 21 (91.3%) clusters. Transmission of infection occurred from an adult to a child in 19 clusters and/or from an adult to another adult in 12 clusters.

There was no evidence of child‐to‐adult or child‐to‐child transmission.Children were more likely to have an asymptomatic infection compared to adults (40% versus 10.5%, p‐value=0.021). In addition, infected children were significantly more likely than adults to have a low viral load (40.7% versus 18.5%, p‐value=0.016). It is noted in the discussion that five clusters came to attention because an infant was hospitalised, but no children required intensive care.

Limitations: it was unclear how clusters were selected and what the exclusion or inclusion criteria were.

This study adds evidence that children are much lower risk than adults for transmission of Covid-19, consistent with them having a low viral load.

Szablewski, CStewart, RMMWRSARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp — Georgia, June 20207 Aug 2020USANorth America409Epidemiology - Transmissionhttp://dx.doi.org/10.15585/mmwr.mm6931e1

Question: The question addressed by this report is the transmissibility of SARS-CoV-2 among children and young people in a group setting. The background is to what extent opening schools after the summer holidays might contribute to community transmission of COVID-19.

Setting: investigation of an outbreak of COVID-19 at a camp for children and young people in Georgia, USA between 17/06/202 to 27/06/2020

Methodology: Department of Public Health outbreak investigation

Results: From 17th – 20th June staff and trainees held orientation course at camp. On 21st June trainees left, staff stayed, and 3 senior staff and 363 campers arrived at camp. Median age campers = 12 years (range 6 – 19), median age of staff = 17 years (range 14 – 59).

Variety of indoor and outdoor activities including daily vigorous singing and cheering

Risk mitigation measures at the camp: -evidence of negative viral SARS-CoV-2 within 12 days of arriving in staff, trainees and campers. -Cloth masks for staff (but not campers), cabin cohorts of <26 people, staggering cohorts for use of outdoors, physical distancing, cleaning and disinfection. -Not implemented: opening windows and doors for increased ventilation.

Index case: a teenage member of staff who developed COVID symptoms on the evening of 22nd June who left the camp on 23rd June.

Case definition: positive viral SARS-CoV-2 test in any camp attendee (staff, trainee or camper) up to 14 days after leaving the camp.

Measure of transmission: attack rates (numbers with positive test/total number of attendees)

Attack rates: -per age group were: 6 – 10 year = 51/100 = 51%, 11 – 17 = 180/409 = 44%, 18 – 21 = 27/81 = 33%, 22 – 59 = 2/7 = 29%.

-per type of attendee: trainee (17th – 21st June) = 26/134 = 19%, staff (17th – 27th June) = 66/117, camper (21st – 27th June) = 168/346 = 49%

Analysis: Transmission from staff is possible and probable, more so than from children:Having a negative COVID test with 12 days of arriving still allows infection and transmission subsequently, after negative test and date of arrival to the camp.This could have happened to member(s) of staff or campers.

Information was not provided on age composition of cabins but likely mixed.

It is estimated that the earliest transmission can occur is after 48 hours after infection. Index case developed symptoms on the evening of the 22nd, less than 48 hours after campers arrived.

On the 21st June, trainees were leaving as campers were arriving. The attack rate among trainees was 19%. It is unlikely that there was an opportunity for transmission from campers to trainees on that day. There infections are more likely to have arisen from contact with an infected fellow trainee or member of staff sometime between 17th and 20th June before the campers arrived.

The likelihood of transmission depends on the amount of contact and susceptibility. The campers were at the camp between 3 and 6 days. Had a camper brought in COVID with them, he/she would have had to have an extremely high rate of contact with many staff, trainees and campers to explain the high attack rates seen in all groups. In addition, the 6 days window (from the 21st June when the campers arrived to the 27th, is a short time and doesn’t allow for a long chain of transmission to explain the high attack rates seen in all groups. A more likely explanation is that the attack rates are the result of multiple chains of transmission arising from an infected staff or trainee early on.

It is possible that cases may have arisen before camp attendance or acquired after campt attendance, up to 14 days after leaving the camp.

Sources of measurement error: In the calculation of attack rates, the denominator was made up of attendees whose viral test result was not available to DPH on the assumption that not all negative results were consistently reported by the laboratory. It is not known how many people were not tested. The specificity of PCR SARS-CoV-2 averages about 70% allowing for false negatives.

Impression: this is a very interesting report, but the data do not support any definitive statement about the ability of children to transmit SARS-CoV-2. The report shows that children can be infected in large outbreaks given the high attack rates, but it doesn’t answer the question on transmissibility by children.

MacCartney, KWood, NLancet Child Adolesc Health Transmission of SARS-CoV-2 in Australian educational settings: a prospective cohort study3 Aug 2020AustraliaAsia22Epidemiology - Transmissionhttps://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30251-0/fulltext

In this epidemiological study from New South Wales (NSW), Australia (state population 8.1 million), the transmission of SARS-CoV-2 in schools and early childhood education centres (ECECs) was examined during the first wave of infections between January 25th to April 9th 2020.  Schools and ECECs remained open throughout the study period with distance learning at schools implemented on March 23rd, and physical attendance limited to children children without other care options - leading to a decrease in attendance from 90% to 10% for the last 2 weeks of the study period.

All adult and paediatric laboratory-confirmed cases of SARS-CoV-2 infection in NSW who attended a school or ECEC whilst infectious were identified. Schools were closed temporarily on initial case notification to allow for contact tracing and generally re-opened after 24-48 hours. Close contacts underwent home quarantine for 14 days after last exposure and were instructed to undergo PCR testing if they developed symptoms of infection. Selected educational settings were offered enhanced investigation of contacts which included upper respiratory tract swab for PCR at day 5-10 and serology testing at day 21 regardless of symptoms. 

In total, 27 index cases were identified including 15 adults and 12 children (median age 15 years (IQR 14-16)) - 8 of whom were in high school. A total of 1448 close contacts were identified, including 633 (44%) who underwent PCR or serology testing. Of 18 secondary cases identified, 10 were children and only 2 were due to child to child transmission. Only 1 case of child to adult transmission was identified; 8 cases of adult to child and 7 cases of adult to adult staff transmission occurred. The overall attack rate was 1.2% - 0.3% for child to child contacts, 1.5% for adult staff to child contacts and 4.4% for adult to adult staff contacts. One large cluster occurred in an ECEC facility with a single adult index case in which 6/12 (50%) adult staff and 7/25 (28%) children were infected. 

This data is in keeping with other school contact tracing studies from Ireland and France demonstrating low attack secondary attack rates in children exposed in educational settings. The higher rate of staff to student and staff to staff transmission relative to transmission from a child index case to others is in keeping with other data suggesting "children are unlikely to initiate or propagate outbreaks". Importantly, the authors point out the intensive tracking and contact tracing in this study was only possible in the context of low numbers of case introductions to schools, underpinned by effective control and suppression of community transmission at a statewide level.

This study highlights that schools are able to be kept open safely with effective case identification and contact tracing in the context of an effective epidemic response in the general population. 

Hecht, JRoberts, DMod PatholSARS-CoV-2 can infect the placenta and is not associated with specific placental histopathology: a series of 19 placentas from COVID-19-positive mothers 2 Aug 2020USANorth America0Epidemiology - Transmissionhttps://doi.org/10.1038/s41379-020-0639-4

Although SARS-CoV-2 infection in pregnant women has been widely documented in a variety of settings, only a handful of cases of probable vertical transmission from mother to fetus have been reported and in only two of these cases was evidence of infection of the placenta provided. The authors of the study reviewed here have sought to determine whether the apparent low frequency of vertical transmission of SARS-CoV-2 is due to a low rate of placental infection and/or a low rate of viral transmission across the placenta.

In this retrospective study the placentas of nineteen women with evidence of Covid-19 infection were examined. All of the women had tested positive to SARS-CoV-2 using commercial assay RNA testing performed of nasopharyngeal swabs. The swabs were taken at an average of three days prior to delivery and the median gestational ages of the pregnancies was 36 weeks and 4 days (range 22- 41 weeks). An additional “negative test” was also included as a “negative control”; this case seems to have been included in the results of the test-positives. The placentas were subjected to the following investigations: gross and histologic examination; evidence of direct placental SARSCoV-2 expression shown by the presence of viral nucleocapsid, using in situ hybridisation (ISH), or of viral RNA, using immunohistochemistry (IHC); evidence of the expression of the receptor protein, ACE2, and the priming protein, TMPRSS2, using IHC; expression of these proteins is required for SARS-CoV-2 to infect the placenta.

For comparison, there were three control groups of placentas: 10 placentas of mothers who had histories and histopathological evidence of RNA viral infections other than SARS-CoV-2; 130 placentas from pregnancies in which the baby suffered hypoxic ischaemic encephalopathy; 120 “normal” controls.

The main findings were that, although there was evidence of ACE2 expression in the syncitiotrophoblast (ST) and extra-villous trophoblast (EVT) of all test-positive placentas, and in the cytotrophoblast of 14, there was SARS-CoV-2 nucleocapsid in only two placentas and SARS-CoV-2 RNA in two. TMPRSS2 expression was only present weakly in the villous endothelium of ten placentas and rarely in the ST. Of note, there was a polarised pattern of ACE2 expression, highest on the stromal side of the ST; this is relatively distant from the maternal circulation. There were no characteristic findings on gross and histologic examination.

The authors conclude that, although the placenta is capable of being infected by SARS-CoV-2, this is a rare event. They speculate that the explanation for placental infection being infrequent may be a combination of the polarised pattern of ACE2 expression “away from the maternal blood” and the “pronounced paucity” of TMPRSS2 expression in the trophoblast.

Madewell, ZDean, NmedRxi (preprint)Household transmission of SARS-CoV-2: a systematic review and meta-analysis of secondary attack rate1 Aug 2020USA InternationalInternationalEpidemiology - Transmissionhttps://www.medrxiv.org/content/10.1101/2020.07.29.20164590v1

This systematic review examined 40 published studies of household secondary transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

The investigators were from the United States. Nineteen of the 40 identified published studies were from China, 5 from South Korea, 4 from the USA, 2 from Spain and one each from Australia, Brazil, Brunei, Germany, India, Israel, Italy, Singapore, Taiwan and the UK. The meta-analysis included all identified publications prior to 29 July 2020.

The secondary attack rate (SAR) for each household or family was calculated as follows: The denominator was the number of exposed contacts, and the numerator was the number who became infected with SARS-CoV-2 or developed COVID- 19. Following meta-analyses, the secondary attack rate (SAR) estimate from all 40 publications was 0.188.

The subgroup secondary attack rate (SAR) estimate from symptomatic index cases to household and family contacts (16 studies) was 0.199 (range 0.039 to 0.446); whereas the subgroup SAR estimate from asymptomatic index cases to household and family contacts (3 studies) was 0.07 (range 0 to 0.054). The analysis also found that household secondary attack rates (SARs) were higher to spouses than other family contacts, and in households with one contact than households with three or more contacts.

The secondary attack rate (SAR) estimate for adult (≥18 years) household and family contacts was 0.310 (range 0.089 to 0.696). The secondary attack rate (SAR) estimate for children (<18 years) household and family contacts was 0.157 (range 0.040 to 0.269) (9 studies).

Stein-Zamir, CMiskin, IEurosurveillanceA large COVID-19 outbreak in a high school 10 days after schools' reopening, Israel, May 202023 Jul 2020IsraelMiddle East1161Epidemiology - Transmissionhttps://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.29.2001352#html_fulltext

This rapid communication (published 23rd July 2020) describes an outbreak of COVID-19 in May 2020 in a public high school in Jerusalem, Israel, shortly after the re-opening of schools after 2 months of mandatory closure.

Background: Israel’s schools were closed by the government on 13th March because of the COVID-19 pandemic and were fully re-opened on 17th May (with a partial re-opening prior to that on 3rd May for kindergartens, grades 1-3 and grades 11-12). Requirements for school re-opening included daily health reports, hygiene, facemasks, social distancing and minimal interaction between classes. The population of Israel is 9.1 million (median age 30 years); the Jerusalem health office serves 1.25 million residents (median age 23.5 years) characterised by moderate to low socioeconomic status and large households.

Outbreak: The school subject to the outbreak was a regional public school with 1,190 students aged 12-18 years (grades 7-12), who travel from suburbs and neighbourhoods by public or school bus, and 162 staff members. The school schedule is 6 days per week for 38-40 hours weekly. The school re-opened after 2 months closure on 18th May: a student case of COVID-19 was notified on 26th May (the source of infection was unknown; at this point close contacts (4 household, 50 students and 14 teachers) were instructed to self-isolate) and then a second student case (in a different grade and epidemiologically unlinked to the first case) was notified on 27th May, at which point the whole school was closed and most of the remaining school community was tested between 28th and 30th May by nasopharyngeal swab PCR for SARS-CoV-2 (26 students and 10 teachers had not attended school since re-opening and were therefore excluded; 1,161/1,164 students and 151/152 teachers were tested) The two initial positive cases attended school 19th to 21st May and reported mild symptoms.

Results of testing: 153/1,161 (13.2%) students (median age 15 yrs for positive cases) and 25/151 (16.6%) staff (median age 40 yrs for positive cases) tested SARS-CoV-2 positive, with males slightly overrepresented in grades 7 to 10 and amongst staff. Gender: 597/1,161 (51%) male of all students tested and 86/597 (14%) of male students positive; 564/1,161 (49%) female and 67/564 (12%) of female students positive; 51/151 (34%) male of all staff tested and 9/25 (36%) of male staff positive; 100/151 (66%) female of all staff tested and 16/100 (16%) of female staff positive. Grades 7-9 (median ages 13-15 yrs) had higher positive rates than grades 10-12 (median ages 16-18 yrs). The age/grade and gender of the two initial cases are not given.

Symptoms reported: The two initial student cases reported mild symptoms (anosmia, ageusia, fever and headache). Questioning of those in the school community with subsequent positive SARS-CoV-2 tests revealed symptoms in 66/153 (43%) of students and 19/25 (76%) of staff. Commonest symptoms reported were cough, headache, fever, sore throat and myalgia. There was one emergency room visit recorded (age of patient not given) and no hospitalisations.

Factors suggested which may have facilitated outbreak: An environmental school inspection reported crowded classes: 35-38 students per class in class areas of 39-49 m2, allowing 1.1-1.3 m2 per student, where distancing between students and between students and teachers was not possible. There was an extreme heatwave from 19th to 21st May during which schoolchildren were exempted from wearing facemasks for 3 days and the school air-conditioning functioned continuously (separate systems for each class). Daily travel time to school approximates to 20-45 minutes on public or school buses. Most students also participate in extracurricular activities such as sports or dance for an average of 2-4 hrs per week. The authors cite the “three C’s” to be avoided to minimise risks of outbreaks: closed spaces with poor ventilation, crowded places and close-contact settings. They reference the European Centre for Disease Prevention and Control’s June 2020 report on air-conditioning and ventilation systems and COVID-19, which recommends increasing air exchange rate and outdoor air use and decreasing air recirculation to reduce spread in indoor spaces.

This study demonstrates the potential for widespread infection with education settings. The chain of transmissions cannot be eludicated from this study. Given the concurrent relaxation of multiple lockdown measures, it is unclear how much transmission occurred within the school and how many cases were imported in following community transmission.

Torres, JPO'Ryan, MClin Infect DisSARS-CoV-2 antibody prevalence in blood in a large school community subject to a Covid-19 outbreak: a cross-sectional study10 Jul 2020ChileS America1000Epidemiology - Transmissionhttps://academic.oup.com/cid/article/doi/10.1093/cid/ciaa955/5869860

This cross-sectional study describes in detail the effects of an outbreak of Covid-19 at a school in Santiago, Chile, probably arising from a single adult index case. As well as PCR nasopharyngeal antigen swabs, they followed up with home-administered blood antibody tests in a stratified sample, and asked staff, students and parents about symptoms and contacts. This presented an opportunity to examine the relationship between symptoms, antigen and antibody positivity across the age range, and the role of asymptomatic transmission, in a previously unexposed population.

The private school has 2600 students across all school years, and 318 staff. The outbreak started on March 13th 2020, only 9 days after Chile’s first case, and spread rapidly, possibly because of a series of parents’ evenings. The school was immediately closed, before the general lockdown in Chile.

Symptomatic, antigen-positive Covid-19 occurred in 7 students, 18 staff and 27 parents. There was one death.

A stratified sample of 1009 students and 235 had home IgG/IgM antibody-testing from 4th-19th May. Of the students, 9.9% were positive; of the staff, 17% were positive. Antibody positivity was associated with younger age (possibly because the index adult dealt with early years children), previous antigen positivity on PCR, and contact with a confirmed case, as expected.

More interestingly, they asked about symptoms through questionnaires: the antibody-positive children reported a range, with the most common being abdominal pain (21%) and fever (17%), but 40% reported no symptoms at all. Of the antibody-positive staff, weakness, myalgia and hyposmia were more prevalent, and 18% had no symptoms. Many of those with symptoms and positive antibodies had had negative antigen tests. Covid-type symptoms occurred in some who were both antigen and antibody negative.

An interesting side-issue is that they found home-testing kits for blood antigens to be effective and acceptable to their population: these could be widely used in seroprevalence studies.

This study cannot answer perhaps the most important question: to what extent can asymptomatic children spread the virus? However, they could conclude that adults (parents and staff) were disproportionately affected in terms of both symptoms and antibody-positivity compared to children, and that control of spread in schools should concentrate on preventing adult-to-adult transmission.

Yung CFThoon KCJ PediatrHousehold Transmission of SARS-CoV-2 from Adults to Children2 Jul 2020SingaporeAsia213Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334921/

This paper from Singapore considers the transmission of SARS-CoV-2 from known infected adults to paediatric household contacts. Data collection was between 5 March 2020 to 30 April 2020 (8 week period). All paediatric household contacts (whether symptomatic or not) of people with confirmed COVID-19 were screened using nasopharyngeal swabs/RT-PCR. 223 adults (from 137 households) had laboratory-confirmed COVID-19. Their paediatric household contacts equated to 213 children (less than 17 years old) who were all tested, and of these, 13 cases were detected (from 7 households). This demonstrates a 6.1% rate of infection among children who were part of households with an individual with laboratory confirmed COVID-19.

Of the 13 cases in children, two children displayed symptoms: one child had a sore throat and one child had an isolated episode of pyrexia.

Looking at age distribution of paediatric household contacts, they found that: - of all those <5 years, 1.3% were infected - of all those 5-9 years, 8.1% were infected - of all those 10-16 years, 9.8% were infected

If the mother was the household index case, the rate of infection in children was highest (11.1%).

It is unclear why the 223 adults who had laboratory-confirmed COVID-19 were initially tested. However, the paper states that patients identified to have COVID-19 were isolated in hospital, so it is also unclear how much exposure the children would have had to the confirmed ‘household’ case of COVID-19.

L'Huillier, AEckerle, IEmerg Infect Dis. Culture-Competent SARS-CoV-2 in Nasopharynx of Symptomatic Neonates, Children, and Adolescents30 Jun 2020SwitzerlandEurope23Epidemiology - Transmissionhttps://wwwnc.cdc.gov/eid/article/26/10/20-2403_article#suggestedcitation

In this study from Switzerland, nasopharyngeal samples of 23 children with PCR confirmed SARS-CoV-2 infection were inoculated into a cell culture to determine the presence or absence of of viable virus. All children aged <16 years, daignsosed at the Geneva University Hospital laboratory between January 25th

 

Of the 23 children with SARS-CoV-2 +ve PCR, median age was 12 years (range 7 days to 15.9 years), the majority (13/23 - 57%) had symptoms of upper respiratory tract infection and 7/23 (30.4%) were admitted to hospital. All samples were taken within 5 days of symptom onset (20/20 where reported), median 2 days (IQR 1-3 days). Median viral load was 3.0 x 10^6 copies / mL (IQR 6.9 x 10^3 - 4.4 x 10^8).

Viable SARS-CoV-2 virus was isolated in half (12/23 - 52%) of children including an infant diagnosed at 7 days of age. Virus isolation was associated with higher viral load (median 1.7 x 10^8 vs 6.9 x 10^3 in culture negative patients).

The results here demonstrate that children with symptomatic SARS-CoV-2 infection have similar viral loads to those seen in adults. Similar to adults, children, particularly those with high viral loads, can also shed viable virus particles early in the course of illness. These findings confirm that transmission of SARS-CoV-2 by children is plausible. It remains however that children appear less susceptible to infection compared with adults in the first instance and when infected tend to experience milder symptoms and therefore as a whole are unlikely to be major drivers of transmission. Indeed, this study identified only 23 paediatric cases of SARS-CoV-2 infection in a region severely affected by the pandemic.

Whilst children with symptomatic SARS-CoV-2 infection can shed viable virus, the small proportion of paediatric cases observed globally indicate a limited role of symptomatic children in disease transmission. 

Fontanet, AHoen, BmedRxivSARS-CoV-2 infection in primary schools in northern France: A retrospective cohort study in an area of high transmission29 Jun 2020FranceEurope510Epidemiology - Transmissionhttps://www.medrxiv.org/content/10.1101/2020.06.25.20140178v2
Yung, CNg, KClincal infectious diseasesNovel coronavirus 2019 transmission risk in educational settings25 Jun 2020SingaporeAsia119Epidemiology - Transmissionhttps://doi.org/10.1093/cid/ciaa794

A study of contact tracing of 3 clusters of confirmed COVID-19 within schools in Singapore. Only close contacts of the affected students were placed into quarantine for 14 days, not complete year groups/schools/or classes. Target health measures implemented included terminal cleaning and interventions to reduce mixing (examples were cancelling of extra-curricular activities and staggered break times). For 3rd incident in day care, the school was closed due to increasing cases amongst staff, and all students were tested regardless of exposure/symptoms.

Case 1: 12yr male in secondary school infected at home (sibling of case 2). Attended on day 1 of symptom and subsequently quarantined. 8 classmates developed compatible symptoms, all tested negative.

Case 2: 5yr male in primary school. Attended on day 1 of symptoms and quarantined. 34 classmates developed compatible symptoms, all tested negative.

Case 3: Multiple adult staff members in pre-school involved in cluster. 70% of all students tested, all negative.

These findings are consistent with the small number of other studies of transmission within a school setting so far, which have demonstrated infrequent transmission from children.

Wongsawat, JDisthakumpa, AJ Paediatr Child HealthRisk of novel coronavirus 2019 transmission from children to caregivers: A case series22 Jun 2020ThailandAsia3Epidemiology - Transmissionhttps://onlinelibrary.wiley.com/doi/full/10.1111/jpc.14965
Ferraiolo AArioni CMedicinaReport of Positive Placental Swabs for SARS-CoV-2 in an Asymptomatic Pregnant Woman with COVID-1922 Jun 2020ItalyEurope1Epidemiology - Transmissionhttps://doi.org/10.3390/medicina56060306
Tomb, RGunson, RJ InfectRetrospective screening for SARS-CoV-2 in Greater Glasgow and Clyde ICUs between December 2019 and February 202015 Jun 2020ScotlandEurope23Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295493/
Rovida, F.Cereda, D.Clin Microbiol InfectLow risk for SARS-CoV2 symptomatic infection and early complications in paediatric patients during the ongoing CoVID19 epidemics in Lombardy12 Jun 2020ItalyEurope27Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289743/
Kayem, G.Winer, N.J Gynecol Obstet Hum ReprodA snapshot of the Covid-19 pandemic among pregnant women in France4 Jun 2020FranceEurope181Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270811
Han, MChoi, EEmerg Infect Dis Viral RNA Load in Mildly Symptomatic and Asymptomatic Children with COVID-19, Seoul4 Jun 2020South Korea Asia12Epidemiology - Transmissionhttps://wwwnc.cdc.gov/eid/article/26/10/20-2449_article
Gao, Y.Xu, R.Indian J Pediatr. Clinical Features and Treatment Protocol in Eleven Chinese Children with Mild COVID-194 Jun 2020ChinaAsia11Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269701/
Nassih, HSab, IIndian J PediarAbsence of Evidence of Transmission of Coronavirus Disease 2019 from a Young Child to Mother Despite Prolonged Contact1 Jun 2020MoroccoNorth Africa1Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292798/pdf/12098_2020_Article_3382.pdf
Somekh, EStein, MPaediatric infectious disease journalThe Role of Children in the Dynamics of Intra Family Coronavirus 2019 Spread in Densely Populated Area1 Jun 2020IsraelMiddle East58Epidemiology - Transmissionhttps://journals.lww.com/pidj/Abstract/9000/The_Role_of_Children_in_the_Dynamics_of_Intra.96128.aspx

This is a brief study of the transmission dynamics within households in Bnei Brak, an area of Isreal with high population density and high proportion of young people (almost 50% of its population are <18yrs). They assessed 13 family clusters and tested every member of their households by PCR, regardless of the presence or absence of symptoms. The index case was identified by date of onset of symptoms (this is standard practice but does leave open the possibility of mis-classifying the index case if they were truly asymptomatic).

The results were as follows; Excluding index cases, 58.3% of adults tested positive, 32.5% of children aged 5 – 17 tested positive, and 11.8% of children aged <5yrs tested positive. In 12/13 families the index case was an adult. The other case was a 14yr old male.

This evidence is consistent with almost all other household contact tracing studies which have demonstrated a significantly lower secondary attack rate in children compared to adults. A strength is the clear documentation that all household members were tested regardless of symptoms, and for clarity the index case was not included in the rates of infection making secondary AR better defined.

Behera, P.Parameswaran, G.F1000Research 9 (no pagination)(315)SARS-CoV-2 epidemic in India: epidemiological features and in silico analysis of the effect of interventions30 May 2020IndiaAsia109Epidemiology - Transmissionhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262570/
Wong, JChaw, L Influenza Other Respir VirusesAsymptomatic transmission of SARS‐CoV‐2 and implications for mass gatherings30 May 2020MalaysiaAsia2Epidemiology - Transmissionhttps://onlinelibrary.wiley.com/doi/full/10.1111/irv.12767
Yang, MSu, WPublic HealthA three-generation family cluster with COVID-19 infection: should quarantine be prolonged?30 May 2020TaiwanAsia1Epidemiology - Transmissionhttps://www.sciencedirect.com/science/article/pii/S0033350620302055
Heavy, LMcDarby, GEuro Surveill No evidence of secondary transmission of COVID-19 from children attending school in Ireland, 202028 May 2020Ireland Europe3Epidemiology - Transmissionhttps://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.21.2000903

This is an epidemiological study describing cases of Covid-19 in Irish school setting in March 2020. Cases were identified by screening all cases of SARS-CoV-2 notified to public health departments in the Republic of Ireland, to identify children under the age of 18 years, and adults who had attended the school setting.

Six cases were identified, 3 school going children, and 3 adults (1 a teacher, and 2 who conducted educational session in a school). 5 out of 6 cases presented symptomatically with fever or cough, the final case was asymptomatic and screened due to a household cluster. Contact-tracing records were reviewed to identify cases of secondary transmission.

A total of 1155 contact of these six cases were identified. In the school setting, among 924 child contacts and 101 adult contacts identified, there were no confirmed cases of COVID-19. The only documented transmission that occurred from this cohort was from an adult case to other adults working environment outside school.

In conclusion no case of onward transmission to other children or adults within the school occurred. In the case of children, no onward transmission was detected at all. Furthermore, no onward transmission from the three identified adult cases to children was identified.

Limitations of the study, was only symptomatic contacts were tested, and so asymptomatic secondary cases were not captured. Also, in Ireland, when a case was identified, all children and staff within the school were excluded thus limiting the potential for further transmission within the school setting once a case was identified. All Irish schools closed on March 12th 2020 and remain closed.

Chen, MZhao, DJournal of Infection and Public HealthA SARS-CoV-2 familial cluster infection reveals asymptomatic transmission to children27 May 2020ChinaAsia2Epidemiology - Transmissionhttps://doi.org/10.1016/j.jiph.2020.05.018
Posfay-Barbe, KL'Huillier, APediatrCOVID-19 in Children and the Dynamics of Infection in Families26 May 2020SwitzerlandEurope40Epidemiology - Transmissionhttps://doi.org/10.1542/peds.2020-1576

This is a report of the first 40 paediatric patients presenting to Geneva University Hospital’s surveillance network (Switzerland). The aim of the study was to describe the clinical presentation of the patients and the dynamics of their familial clusters. Out of a total of 4310 SARS-CoV-2 cases, 40 (0.9%) were in children <16 years.

Clinical Presentation: Patients presented to medical care, and were confirmed via RT-PCR. Median age, years (IQR) 11.1 (5.7-14.5), 22/40 (56%) were female. The most common presentation was cough 32 (82%), Fever 26 (67%), nasal discharge 25 (64%). Most were previously healthy; with comorbidities reported in only 26% of patients; asthma (10%), diabetes (8%), obesity (5%), premature birth (5%) and hypertension (3%). Seven patients were admitted, none needed ICU care or Sars Cov2 specific therapy

Family Clusters: Family cluster evaluation was conducted by phone. 111 household contacts (HHC) were identified; 39 mothers, 32 fathers, 23 pediatric siblings, 8 adult siblings and 7 grandparents.

Family member was suspect if they had fever of acute respiratory symptoms. 61/111 had RT-PCR conducted. 77% (85/111) of household contacts (HHC) were symptomatic. Adult HHC were suspected or confirmed to have covid symptoms before the child 79% (31/39) of cases. In only 8% (3/39) of households did the study child develop symptoms first. 85% (75/88) of adult HHC developed symptoms at some point, compared to 43% (10/23) of pediatric HHC, which was statistically significant (p<0.001). Mothers were statistically more likely to develop symptoms than fathers (36/39 v 24/32, p=0.04). Due to the need for symptoms to qualify for testing, there is the possibility of undercounting paediatric infections due to their being more likely to have asymptomatic or oligosymptomatic infection.

The authors conclude that children are uncommonly the index case in family clusters of Sars CoV2. Household contacts who are children are less likely to be symptomatic than adult contacts. Children are most likely to be infected inside of family clusters, albeit at a time in Switzerland when creches and schools were closed.

De Ioris, MRaponi, MJ Pediatric Infect Dis SocDynamic viral SARS-CoV-2 RNA shedding in children: preliminary data and clinical consideration of Italian regional center23 May 2020ItalyEurope22Epidemiology - Transmissionhttps://academic.oup.com/jpids/advance-article/doi/10.1093/jpids/piaa065/5842265?searchresult=1

This study at a paediatric hospital in Rome tracked SARS-CoV-2 shedding (nasopharyngeal, faecal, urinary and conjunctival) by following a cohort of 22 children during their hospital stay, collecting clinical and microbiological data.

Study design: The study ran from 16th March to 12th April in the COVID centre at Bambino Gesu Pediatric Hospital and collected data on 22 inpatients with an initial positive nasopharyngeal swab (either prior to admission or on admission). RT-PCR for SARS-CoV-2 RNA on nasopharyngeal and conjunctival swabs and stool and urine samples were repeated every 2-3 days for each child while they were inpatients until they had two consecutive negative results in the absence of new symptoms. Kaplan-Meier analysis was used to estimate the duration of symptoms and viral shedding for symptomatic patients: patients whose last swab/sample was still positive were censored at the date of the last swab.

Study population: 15/22 (68%) male, 7/22 (32%) female. Median age 7 years (range 8 days to 17.5 years). 4/22 neonates (1/4 tested because mother positive and 3/4 tested because midwife positive). 2/22 comorbidity (Angelman syndrome, suspected genetic syndrome and autism). 13/22 patients were discharged before the end of the study period (median inpatient stay 7 days, range 3-15 days).Symptoms: 4/22 (18%) asymptomatic (including 2/4 neonates, the other 2/4 had low grade fever and poor feeding). 18 symptomatic patients: 15/18 (83%) fever, 10/18 (55%) respiratory symptoms, 7/18 (39%) diarrhoea and vomiting, 3/18 (17%) seizure. Symptoms had resolved in all 18 before discharge from hospital. Median duration of symptoms was 8 days (range 2-21 days). 15/22 had a positive stool sample at admission: of these 7/15 (47%) had respiratory symptoms and 3/15 (20%) had diarrhoea and vomiting.

Viral shedding: At diagnosis: 22/22 (100%) had positive nasopharyngeal swab (by definition), 15/22 (68%) had positive stool sample, 1/22 (5%) had positive urine sample (re-test 2 and 5 days later was negative; another patient had initial negative urine test but repeat 3 days later was positive) and 2/22 (9%) had positive conjunctival swab (both were negative 2-3 days later). A detailed table charting the dates of inpatient stay, onset and end of symptoms and positive/negative swabs/samples for each patient is supplied: the full screen of faecal, urinary and conjunctival sampling was performed at variable intervals after the initial positive nasopharyngeal swab (up to 5 days later in several cases). For symptomatic patients: (1) from date of symptom onset to negative nasopharyngeal swab: median 8 days (range 2-17 days) and (2) from date of symptom onset to negative stool sa