Recognizing, Alerting Parents About Severe COVID-19 in Pediatric Patients

Most pediatric patients have mild symptoms from COVID-19 if they have any symptoms at all. But, as pharmacists understand, most is not all. Find out what patient characteristics and symptoms are suggestive of a more severe response requiring immediate medical care.

HOUSTON – While younger people -- children, teens and young adults – generally are at lower risk for severe complications from COVID-19, that doesn’t equate to no risk.

A report in JAMA Pediatrics suggests their danger of having a serious case might be greater than previously suspected.  than previously thought and those with underlying health conditions are at even greater risk, according to a study coauthored by a Rutgers researcher.

Researchers from Texas Children’s Hospital, Baylor College of Medicine, and colleagues are the first to describe the characteristics of seriously ill pediatric COVID-19 patients in North America.

"The idea that COVID-19 is sparing of young people is just false," said coauthor Lawrence C. Kleinman, MD, MPH, of Rutgers Robert Wood Johnson Medical School. "While children are more likely to get very sick if they have other chronic conditions, including obesity, it is important to note that children without chronic illness are also at risk. Parents need to continue to take the virus seriously."

In mid-March, more than 300 pediatric ICU (PICU) and infectious disease specialists from more than 100 of the largest pediatric hospitals across six continents joined together to share best practices and real-time information from across the world on critical illness caused by COVID-19 in children.

In the group, which has met by virtual meeting platforms on a twice weekly or weekly basis, are more than 50 North American pediatric hospitals participating and submitting data to the collaborative. In this report, the authors seek to provide an early description and characterization of COVID-19 infection in North American PICUs, focusing on mode of presentation, the presence of comorbidities, therapeutic interventions, severity of disease and clinical course, and early outcomes.

In this cross-sectional study of 46 North American PICUs, between March 14 and April 3, 2020, 48 children were admitted to 14 PICUs in the United States and none in Canada. With a median age of 13, 52% of the children were male.

Of those children admitted, 83% had preexisting underlying medical conditions, 73% presented with respiratory symptoms, 23%) had failure of two or more organ systems and 38% required invasive ventilation. Researchers point out that the hospital mortality rate was 4.2%.

This early study shows that COVID-19 can result in a significant disease burden in children but confirms that severe illness is less frequent, and early hospital outcomes in children are better than in adults,” the study notes.

Targeted therapies were used in 28 patients (61%), with hydroxychloroquine being the most commonly used agent either alone (11 patients) or in combination (10 patients). At the end of the study period, nearly a third of the pediatric patients were still hospitalized. For those who had been discharged, median (range) PICU and hospital lengths of stay for those who had been discharged were 5 (3-9) days and 7 (4-13) days, respectively.

“Prehospital comorbidities appear to be an important factor in children,” the authors point out. “These preliminary observations provide an important platform for larger and more extensive studies of children with COVID-19 infection.”

In addition to some children having severe COVID-19 cases in line with what adults are experiencing, a few children have experienced Kawasaki-like disease linked to the pandemic. An American Heart Association press release points out that, while most children infected with the novel coronavirus are asymptomatic or exhibit only mild symptoms, a small number of children in the United States and elsewhere developed a more serious inflammatory syndrome with COVID-19 in the past two months. Most were hospitalized, some required intensive care, and a few died.

Children with the condition have a persistent fever, inflammation and evidence of single or multi-organ dysfunction -- shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder – and might or might not test positive for COVID-19, according to the AHA.

“We want to reassure parents – this appears to be uncommon. While Kawasaki disease can damage the heart or blood vessels, the heart problems usually go away in five or six weeks, and most children fully recover,” explained Jane Newburger, MD, MPH, of  the Kawasaki Program at Boston Children’s Hospital; and Commonwealth Professor of Pediatrics at Harvard Medical School.. “Rarely, but sometimes, the coronary artery damage persists. Because of this, Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. Prompt treatment is critical to prevent significant heart problems.”

New York public health officials said they were investigating more than 100 reported cases where children - predominantly school-aged - were experiencing symptoms similar to an atypical Kawasaki disease or a toxic shock-like syndrome possibly due to COVID-19. As of May 12, three young people had died, and two additional deaths were under investigation. Cases also were identified in 14 other states.

New York said parents and caregivers should seek immediate care if a child has:

  • Prolonged fever (more than five days)
  • Difficulty feeding (infants) or is too sick to drink fluids
  • Severe abdominal pain, diarrhea or vomiting
  • Change in skin color - becoming pale, patchy and/or blue
  • Trouble breathing or is breathing very quickly
  • Racing heart or chest pain
  • Decreased amount of frequency in urine
  • Lethargy, irritability or confusion

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