|
 
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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 9
| Issue : 1 | Page : 7-9 |
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Pediatric COVID-19: Revision before resumption
Surabhi Chandra
Department of Pediatrics, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| Date of Submission | 13-Jul-2020 |
| Date of Decision | 14-Aug-2020 |
| Date of Acceptance | 26-Aug-2020 |
| Date of Web Publication | 06-Nov-2020 |
Correspondence Address:
Dr. Surabhi Chandra
SRMS Institute of Medical Sciences, Bareilly - 243 202, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpai.jpai_1_20
With staged unlocking, physical opening of classes and schools is not distant. There is an urgent need to revise all salient points of this infection in children. Infection spreads mainly via droplets, fomites and contact with infected surfaces even though feco-oral route of transmission has also been reported. Majority of cases are asymptomatic or have mild illness. Children who have been diagnosed as positive usually have familial clustering. A positive history of exposure and clinical symptoms are more helpful for screening. Confirmation of the diagnosis is on the basis of a positive RT-PCR. Most common symptoms having been reported are fever and cough. Complete blood counts are suggestive of leucopenia with relative lymphopenia. Management of COVID 19 in children is primarily supportive. Prevention is the key to successful outcome in patients with COVID-19
Keywords: Pediatric COVID-19, RT-PCR, children
How to cite this article:
Chandra S. Pediatric COVID-19: Revision before resumption. J Pediatr Assoc India 2020;9:7-9 |
| Introduction | |  |
With staged unlocking, physical opening of classes and schools is not distant. There is still an ongoing upsurge in the total number of confirmed cases, and data on pediatric coronavirus disease 2019 (COVID-19) are lacking. An empirical case projection study from the USA says that a surge in severe cases in children would present unique challenges for hospitals and public health preparedness.[1]
There is an urgent need to revise all salient points in the epidemiology, pathophysiology, screening, diagnosis, clinical presentation, management, and prevention of COVID-19 infection in children to keep a high index of suspicion and for early recognition and timely management in them.
| Epidemiology | | |
Even as the nCoV (novel coronavirus) disease is growing rapidly, data on symptoms and prognosis in children are limited.[2]
The infection spreads mainly via droplets, fomites, and contact with infected surfaces,[3] even though feco–oral route of transmission has also been reported.[4] Pediatric cases have been found to be 1%–5% of the total affected population in various studies.[2],[5] Majority of the cases are asymptomatic or have mild illness.[6],[7],[8] Infants and young children have relatively more severe disease than older children.[3],[9] Mortality though low is still reported, including perinatal deaths.[10],[11],[12] No specific sex predilection has been seen.[13],[14]
Children who have been diagnosed as positive usually have familial clustering and, in most of the cases, a positive adult contact is usually identifiable.[7],[8],[15] While some studies found no evidence to prove vertical transmission from mother or via breast milk to a neonate,[16],[17] a recent review suggests that the possibility of the same cannot be completely ruled out.[11]
| Pathophysiology | | |
Numerous postulations have been put forward to explain the relatively benign nature of COVID-19 illness in children. These include timely closure of schools and colleges, less expression of the ACE-2 receptors (primary target receptors of SARS-CoV-2), strong innate immune response due to trained immunity (different vaccinations), less ability to mount the dysfunctional hyper-inflammatory response, and relative lack of comorbid conditions, smoking, and obesity.[18]
A recent epidemiological review cited that children are as likely to become infected as adults.[18],[19] Children might be asymptomatic carriers, but their importance as disease spreaders is not yet certain.[7]
| Screening | | |
A positive history of exposure and clinical symptoms is more helpful for screening children with COVID infection rather than screening with computed tomography (CT) thorax, compared to adults (in whom it has been found to be a better screening investigation in both laboratory-confirmed and clinically diagnosed cases).[20]
| Diagnosis | | |
As per the current testing strategy of the Indian Council of Medical Research[21] dated May 18, 2020, a set of nine criteria have been mentioned for testing. Of these specific criteria which may pertain to a clinical suspicion of COVID-19 in children are:
- Symptomatic influenza-like illness (ILI, i.e., fever [≥38○ C] + cough) contacts of laboratory-confirmed cases
- Symptomatic ILI within hotspot or containment areas
- Symptomatic ILI in returnees and migrants within 7 days of illness
- Severe acute respiratory illness, i.e., fever (≥38○ C) + cough + requiring hospitalization
- Hospitalized children developing ILI symptoms.
Confirmation of the diagnosis is on the basis of a positive reverse transcriptase-polymerase chain reaction (PCR) on a nasopharyngeal (preferable) or an oropharyngeal swab sample. A review of patients (both adults and children with gastrointestinal manifestations) suggests that fecal PCR testing is as accurate as respiratory PCR, becomes positive 2–5 days later and persists up to 1–11 days after that in the latter.[22] Antibody tests are yet not recommended for establishing the diagnosis.
| Clinical Presentation | | |
Coronaviruses are mostly known to cause respiratory and gastrointestinal symptoms. The usual presentation is that of involvement of the respiratory system. The disease spectrum may vary from mild upper respiratory illness to pneumonia to even acute respiratory distress syndrome. This may also be accompanied with multiorgan dysfunction and septic shock in severe cases. The most common symptoms that have been reported are fever and cough in varying percentages.[8],[11],[15],[23] Breathlessness is the next common symptom. Rhinorrhea is a less common manifestation[7] (unlike the usual feature of other viral upper respiratory infections).
Gastrointestinal symptoms such as anorexia, diarrhea, nausea, vomiting, and abdominal pain have also been reported in children.[22]
Multisystem inflammatory syndrome in children presents with fever, diarrhea, shock, variable presence of rash, conjunctivitis, mucosal changes, and extremity edema,[24] akin to the features of Kawasaki's disease. Hyperinflammation and cytokine storm are responsible for the multiorgan failure seen in these cases.[5],[25]
Atypical dermatological features such as rash of unknown etiology and facial ulcerations have also been reported.[26]
| Laboratory Investigations | | |
Complete blood counts are suggestive of leukopenia[8],[15] with relative lymphopenia (unlike other viral respiratory illnesses). A single-center retrospective study on fifty children did have lymphopenia in the majority, but thrombocytopenia, lymphocytosis, thrombocytosis, and high hemoglobin were also seen in some children.[27] Another study, on the other hand, has reported leukocytosis and lymphocytosis in six of the nine children studied.[28]
Inflammatory markers such as serum C-reactive protein, procalcitonin, ferritin, and serum interleukin-6 levels are typically raised[8] but to a lesser extent compared to adults, as revealed by a recent systematic review.[2]
Chest X-ray in pediatric patients with COVID is nonspecific with features such as patchy consolidation and bronchial wall thickening.[14]
CT thorax in pediatric COVID cases may show focal ground-glass opacities or consolidation with multilobar involvement as seen in various small cohorts studied.[20],[29] A retrospective study done on 76 children[27] found that an overwhelming number of pediatric patients had lesions in the subpleural area (95%) and 22 of the 28 lower lobe lesions were in the posterior segment (78%).
Lung ultrasound has not been studied extensively in pediatric patients with COVID-19, but vertical artifacts (70%), pleural irregularities (60%), areas of white lung (10%), and subpleural consolidations (10%) have been reported in a study[30] with no evidence of pleural effusion.
| Management | | |
Management of COVID-19 in children is primarily supportive. Oxygen, inhalation therapy, good nutritional support, and maintenance of proper fluid–electrolyte balance are the cornerstones of managing COVID infection in children.[2] As of now, no specific drug is approved for children even though some studies have reported the variable use of antivirals (lopinavir/ritonavir)[3],[8] and even the antimalarial drug hydroxychloroquine.[3]
All efforts should be made to minimize the risk of aerosol generation and hence nebulization is preferably avoided. Metered dose inhaler with spacer is the recommended mode of delivering bronchodilators. Intubation should be done for the usual indications.
| Prognosis and Outcome | | |
Coronaviruses, in general, including SARS-CoV-2, affect children less commonly and cause fewer symptoms and less severe disease with lower case fatality rates compared to adults.[2],[3],[7],[31]
Factors associated with severe disease in children have been found to be lymphopenia, hyperthermia and elevated procalcitonin, d-dimer, and creatine kinase-MB.[8] A study from Wuhan suggested similar findings.[23] They also found that involvement of more than three lung segments on CT thorax is associated with greater risk of development of severe disease in children.
| Prevention | | |
Prevention is the key to successful outcome in patients with COVID-19. Hence, airborne and contact precautions are a must. These include social distancing, use of mask, and regular hand sanitization. Moreover, good immunity plays a major role against severe disease.
Use of face masks in children is preceded by parental and school education on this issue and other hygiene-related topics with an aim to achieve maximal child cooperation.[32]
Vaccine trials are ongoing, but a definitive prevention modality is still in waiting stage.[33]
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
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