PEDIATRIC CORNER

• Recently, there have been alerts from different countries of a small increase in children presenting with a more serious inflammatory syndrome, including features of toxic shock and/or Kawasaki disease (KD), possibly associated with SARS-CoV-2.(1,2,3,4) Some of these children have tested positive by RT-PCR for SARS-CoV-2, but causality has not been established. A portion of these children have required treatment in an intensive care unit.

​​

• It remains true that the majority of children infected with SARS-CoV-2 are either asymptomatic or mildly symptomatic with the rare case requiring hospitalization or resulting in death (see March 21, 2020).

​

• United Kingdom’s Royal College of Paediatrics and Child Health have proposed the following case definition:(5)

  • A child presenting with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder) with additional features (see Appendix 1). This may include children fulfilling full or partial criteria for Kawasaki disease.

  • Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, infections associated with myocarditis such as enterovirus.

  • SARS-CoV-2 PCR testing may be positive or negative

 

• In Montreal, a small cluster of children with severe inflammatory syndromes is being investigated for possible association with SARS-CoV-2.(3) All of the children have tested negative for SARS-CoV-2, but further investigation is ongoing. One hospital in Montreal has noted a slight increase in children with symptoms of KD. The hospital has treated approximately 20 children with symptoms of KD since the end of March, only one required treatment in the intensive care unit and there were no fatalities.

 

• With respect to KD, the underlying etiology is unclear. A viral etiology has been hypothesized, but remains uncertain despite investigations into specific viruses including coronaviruses.(6,7) In studies prior to the COVID-19 pandemic, less than half of those with KD tested positive for respiratory viruses by PCR with rhinovirus being the most commonly identified.

​

​​

1. Paediatric Intensive Care Society. PICS statement: increased number of reported cases of novel presentation of multisystem inflammatory disease [Internet]. [place unknown]: PICS; 2020 Apr 27 [cited 2020 May 6].

2. Daskalakis DC. 2020 health alert #13: pediatric multi-system inflammatory syndrome potentially associated with COVID-19 [Internet]. [place unknown]: New York City Health Department; 2020 May 4 [cited 2020 May 6].

3. Grant K. Doctors to study possible COVID-19 link to kids with rare disease. The Globe and Mail [newspaper on the Internet]. 2020 May 06 [cited 2020 May 6];Canada:[about 2 p.].

4. Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr [Internet]. 2020 Apr [cited 2020 May 06];pii: hpeds.2020-0123.

5. Health Policy Team. Guidance – Paediatric multisystem inflammatory syndrome temporally associated with COVID-19. Royal College of Paediatrics and Child Health [Internet]. 2020 May 01 [cited 2020 May 08]; UK.

6. Turnier JL, Anderson MS, Heizer HR, Jone PN, Glodé MP, Dominguez SR. Concurrent Respiratory Viruses and Kawasaki Disease. Pediatrics [Internet]. 2015 Sep [cited 2020 May 06];136(3):e609-14.

7. Kim JH, Yu JJ, Lee J, et al. Detection rate and clinical impact of respiratory viruses in children with Kawasaki disease. Korean J Pediatr [Internet]. 2012 Dec [cited 2020 May 06];55(12):470-3.

• Dermatologists and pediatricians have noticed a markedly increased prevalence of erythematous, edematous, and blistering, chilblain-like lesions to the fingers and toes of children. They have also been reported in adults. This was first reported in Spain and Italy. Physicians have associated the cutaneous changes with SARS-CoV-2 because of the temporal relationship with the pandemic, the exposure history of some of the patients, and the relatively unique appearance of the lesions.(1,2) However, causality has not been established.

​​

• In a case series of 63 patients, the cutaneous findings were limited to the feet in 85.6%, limited to the hands in 6%, and affecting both hands and feet in 7% of patients.(1) Rarely, elbow lesions have been seen.(2,3) Some patients reported pain and/or pruritis associated with the lesions.(1) In most cases, lesions self-resolved in 2-4 week.(2) 

​​

• Other symptoms are occasionally reported. In the above-mentioned study of 63 patients, 11.1% of patients had GI symptoms, 7.9% had respiratory symptoms and 4.8% had fever, all of which typically preceded cutaneous findings.(1) In this study, 11 patients had a nasopharyngeal (NP) swab taken of which two were positive for SARS-CoV-2. 10 patients had exposure to confirmed or suspected familial cases of COVID-19. A larger study of children and adults with skin lesions (n=132) reported that 2/11 patients who had a NP swab were positive for SARS-CoV-2.(3) They also reported that 40.9% of patients had exposure to a confirmed case. However, in a study of 11 patients, all of the three NP swabs and two rectal swabs were negative for SARS-CoV-2.(2) Additional case reports have described similar skin lesions, but did not perform testing for SARS-CoV-2.(4) 

 

• Some physicians have suggested that the cutaneous findings are a late-stage manifestation or a post-viral phenomenon as the reason for negative RT-PCR tests.(2,5)

​

• The Canadian Pediatric Surveillance Program has advised that if these cutaneous changes are seen, testing should be done for SARS-CoV-2 to allow for contact tracing and self-isolation, if indicated.

​

​​

1. Piccolo V, Neri I, Filippeschi C, Oranges T, Argenziano G, Battarra VC, et al. Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients. J Eur Acad Dermatol Venereol 2020;1. 

2. Recalcati S, Barbagallo T, Frasin LA, Prestinari F, Cogliardi A, Provero MC, et al. Acral cutaneous lesions in the Time of COVID-19. Journal of the European Academy of Dermatology 2020;1. 

3. Fernandez-Nieto D, Jimenez-Cauhe J, Suarez-Valle A, Moreno-Arrones OM, Saceda-Corralo D, Arana-Raja A, et al. Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak. Journal of the American Academy of Dermatology 2020.  

4. Mazzota F et. al. Acute Acro-Ischemia in a Child at the time of COVID-19. Dermatologica Pediatrica, 2020 April 11.

5.  

• There is currently no evidence that antiviral treatment improves outcomes in pediatric patients with COVID-19.(1,2) As well, the use of antivirals is not recommended for pediatric patients outside the context of a clinical trial.

​​

• A recent guidance from a panel of North American pediatric infectious disease physicians and pharmacists suggests that supportive care alone is appropriate for almost all children with COVID-19.(3) According to the guidance, antivirals could be considered in a child with severe disease and should be considered in critical disease. If an antiviral is used, preferably in the context of a clinical trial, the panelists recommend remdesivir as the preferred agent and hydroxychloroquine as an alternative. There was no consensus on whether lopinavir-ritonavir should be considered for the treatment of any pediatric patient with COVID-19. It is important to remember that at this time, all these drugs are investigational for COVID-19 and so far, none have proven to be effective.

​​

• Currently, there is one active clinical trial in Canada investigating antivirals that includes pediatrics. Lopinavir-ritonavir is being investigated for post-exposure prophylaxis (CORIPREV-LR trial) and is actively recruiting in British Columbia and Ontario.

​​

• Health Canada has also authorized an expanded access treatment protocol for remdesivir that includes pediatric patients >12 years and >40 kg who require mechanical ventilation.(4) The protocol is connected to clinical trials outside of Canada investigating remdesivir for those with moderate and severe COVID-19.(5,6) There is also a clinical trial outside Canada that accepts pediatric patients investigating hydroxychloroquine, azithromycin, or both for the treatment of COVID-19.(7)

​

​​

1. Chan K, Beck C, Chauvin-Kimoff L, Gripp K, Krmpotic K, Thakore S, et al. Practice Point: the acute management of paediatric coronavirus disease 2019 (COVID-19) [Internet]. Ottawa: CPS; 2020 Apr 20 [updated 2020 Apr 24; cited 2020 Apr 28].

2. Shi Q, Zhou Q, Wang X, Liao J, Yu Y, Wang Z, et al. Antiviral agents in children with COVID-19 potential effectiveness and safety of antiviral agents in children with coronavirus disease 2019: a rapid review and meta-analysis. medRxiv [preprint]. 2020. [posted 2020 Apr 17; cited 2020 Apr 28].  

3. Chiotos K, Hayes M, Kimberlin DW, Jones SB, James SH, Pinninti SG, et al. Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2. J Pediatric Infect Dis Soc [Internet]. 2020 Apr 22 [cited 2020 Apr 29]: pii: piaa045.  

4. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine; [date unknown]. Expanded Access Treatment Protocol: Remdesivir (RDV; GS-5734) for the Treatment of SARS-CoV2 (CoV) Infection (COVID-19); 2020 Mar 27 [updated 2020 Apr 30; cited 2020 Apr 30].  

5. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine; [date unknown]. Study to Evaluate the Safety and Antiviral Activity of Remdesivir (GS-5734™) in Participants With Moderate Coronavirus Disease (COVID-19) Compared to Standard of Care Treatment; 2020 Mar 3 [updated 2020 Apr 24; cited 2020 Apr 30].

6. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine; [date unknown]. Study to Evaluate the Safety and Antiviral Activity of Remdesivir (GS-5734™) in Participants With Severe Coronavirus Disease (COVID-19); 2020 Mar 3 [updated 2020 Apr 29; cited 2020 Apr 30].

7. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine; [date unknown]. Pragmatic Factorial Trial of Hydroxychloroquine, Azithromycin, or Both for Treatment of Severe SARS-CoV-2 Infection; 2020 Apr 6 [updated 2020 Apr 24; cited 2020 Apr 30].

• For children with asthma, the Canadian Pediatric Society (CPS) recommends that current management plans be continued including short course of oral corticosteroids for acute exacerbations if indicated.(1) Furthermore, for children with suspected exposure or confirmed infection with SARS-CoV-2 and an acute exacerbation of asthma, concerns regarding risk of oral corticosteroid use should be balanced with the general consensus that aggressive management of asthma exacerbations is beneficial. A previously conducted meta-analysis of children with asthma on inhaled corticosteroids (ICS) versus placebo found no increase in non-COVID-19 respiratory infections between groups.(2) Data specific to risk of COVID-19 infection is not available.

​​

• Whenever possible, asthma medications should be administered using metered dose inhaler (MDI) to avoid the aerosolization associated with nebulized medications.(1)

​​

• For children diagnosed with croup during the COVID-19 pandemic, the CPS recommends against oral corticosteroids for treatment of mild cases in older children who are not distressed.(3) This is a change from their usual guidance to consider oral corticosteroid treatment in all children presenting with croup.

​​

• Small numbers of children with inflammatory bowel disease (IBD) have been diagnosed with COVID-19 while continuing immunosuppressive medications without reported adverse outcomes.(4) Consensus guidelines for IBD and rheumatological conditions in pediatrics recommend continuing immunosuppressant therapy as usual, during the pandemic, to prevent disease flare.(4,5) Further recommendations are that corticosteroids should be considered to treat IBD flares during the pandemic,(4) while children with juvenile idiopathic arthritis (JIA) on corticosteroids are advised to consult their rheumatologist for possible dose adjustment.(5) Children with IBD or JIA presenting with acute febrile illnesses should generally have immunosuppressive treatment suspended, in consultation with their specialist, until fever subsides, irrespective of SARS-COV-2.

​

1. Canadian Paediatric Society. Paediatric asthma and COVID-19 | Canadian Paediatric Society n.d. (accessed April 29, 2020).

2. Cazeiro C, Silva C, Mayer S et al. Inhaled Corticosteroids and Respiratory Infections in Children With Asthma: A Meta-analysis. Pediatrics 2017:139.

3. Canadian Paediatric Society. The acute management of paediatric coronavirus disease 2019 (COVID-19) | Canadian Paediatric Society n.d. (accessed April 29, 2020).

4. Turner D, Huang Y, Martin-de-Carpi J et al. COVID-19 and paediatric inflammatory bowel diseases: Global Experience and Provisional Guidelines (March 2020) from the Paediatric IBD Porto group of ESPGHAN. Journal of Pediatric Gastroenterology and Nutrition [PREPRINT] 2020.

5. Paediatric Rheumatology European Association. PRES recommendations in the corona era - COVID-19. Paediatric Rheumatology European Society n.d. (accessed April 29, 2020).

• There has been concern that children could be disproportionately responsible for SARS-CoV-2 transmission due to milder clinical presentation or asymptomatic infections.(1,2) The infection rate amongst pediatric healthcare workers (HCWs) as compared to adult care providers is of interest to  help determine if children are driving ongoing SARS-CoV-2 transmission and to determine if pediatric HCWs are at a higher risk of developing COVID-19.

 

• Data determining the rate of pediatric HCW infection in comparison to adult HCWs is extremely limited. A preprint study from Spain found that 38% of tested hospital employees (791 of 2,085) were positive for SARS-CoV-2.(3) Of the tested employees, 109 worked within pediatric/neonatal environments and 53 (48.6%) were COVID-19 positive, which is 6.7% of the overall SARS-CoV-2 positive employees. It is not clear if the HCWs acquired their infection from occupational exposure.

​​

• While data is limited, current evidence suggests that the infection rate in pediatric HCWs is similar to that of adult HCWs, which does not support the hypothesis that children are disproportionately responsible for transmission of SARS-CoV-2, although this may not hold true outside of the occupational setting. Despite this, in the WHO-China Joint Mission Report completed February 16-24, there were no confirmed cases of asymptomatic child to adult transmission in China.(4) 

​

​​

1. Rezaei N. Letter to the Editor: COVID-19 affects Healthy Pediatricians more than Pediatric Patients. Infect Control Hosp Epidemiol 2020:1–3.

2. Kelvin, AA, Halperin, S. COVID-19 in Children: the link in the transmission train. Lancet Infect Dis. 2020. 

3. Folgueira MD, Munoz-Ruiperez C, Alonso-Lopez MA, Delgado R. SARS-CoV-2 infection in Health Care Workers in a large public hospital in Madrid, Spain, during March 2020. [Preprint] MedRxiv 2020.

4. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 2020.

• In Manitoba, there is a substantially higher number of COVID-19 cases in the 20-29 year age group compared to the 10-19 year age group.(1) This is also seen in other jurisdictions.(2) It is not clear from current evidence how much of this difference is accounted for by asymptomatic or mildly symptomatic cases or differences in testing between these age groups.

​​

• In a study of 46,506 confirmed COVID-19 cases in Italy, those aged 7-19 years were the least likely to require hospitalization.(3) In a study of USA cases <18 years old, there were 745 cases with known hospitalization status of which there was little variation in the percentage of patients hospitalized within the four age categories of 1-4, 5-9, 10-14, and 15-17 years.(4)

​​

• One study compared 14 individuals aged 10-24 years and 32 individuals aged 25-35 years hospitalized with confirmed COVID-19 in China.(5) A greater proportion of those aged 25-35 had derangements in all categories of lab values at admission with the exception of elevated D-dimer and total bilirubin. A smaller proportion of those aged 10-24 required oxygen therapy.

​​

​

1. Province of Manitoba. COVID-19 novel coronavirus: COVID-19 updates [Internet]. [place unknown]: Province of Manitoba; [date unknown] [updated 2020 Apr 22; cited 2020 Apr 22].

2. Korean Society of Infectious Diseases, Korean Society of Pediatric Infectious Diseases, Korean Society of Epidemiology, Korean Society for Antimicrobial Therapy, Korean Society for Healthcare-associated Infection Control and Prevention, Korea Centers for Disease Control and Prevention. Report on the epidemiological features of coronavirus disease 2019 (COVID-19) outbreak in the Republic of Korea from January 19 to March 2, 2020. J Korean Med Sci [Internet]. 2020 Mar 16 [cited 2020 Apr 21];35(10):e112.

3. Riccardo F, Ajelli M, Andrianou X, Bella A, Del Manso M, Fabiani M, et al. Epidemiological characteristics of COVID-19 cases in Italy and estimates of the reproductive numbers one month into the epidemic. medRxiv [preprint]. 2020. [posted 2020 Apr 11; cited 2020 Apr 21].(

4. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep 2020 [cited 2020 Apr 22];69:422–426.

5. Liao J, Fan S, Chen J, Wu J, Xu S, Guo Y, et al. Epidemiological and clinical characteristics of COVID-19 in adolescents and young adults. medRxiv [preprint]. 2020. [posted 2020 Mar 12; cited 2020 Apr 21]. ​

• The Canadian Paediatric Society (CPS), CDC, and WHO all recommend the continuation of routine immunizations during the COVID-19 pandemic.(1,2,3) Be aware of any missed vaccines that would have normally been given in school-based vaccination programs and provide catch-up as soon as possible.(1)

​​

• The CDC and WHO recognize that context is important and, in some circumstances, routine immunizations may not be possible. When only limited well-child visits are possible, the CDC recommends the prioritization of newborn care and vaccination through 24 months of age.(2,3)

​​

• The CPS and CDC outline ways that clinicians may prevent spread where in-person visits are unavoidable including scheduling well visits earlier in the day and sick visits later in the day, dedicating specific rooms for well visits, and limiting the number of people accompanying patients.(1,2)

​​

• The WHO advises increased surveillance of vaccine preventable diseases and the need to have strategies for catch-up vaccination.(3) Disruption to immunization programs during a pandemic can lead to outbreaks of vaccine preventable diseases. For example, following a recent Ebola outbreak, there was a measles outbreak in a region of Guinea.(4,5)

​

1. Nicole Le Saux, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Practice point: Current epidemiology and guidance for COVID-19 caused by SARS-CoV-2 virus, in children: March 2020 [Internet]. Ottawa: CPS; 2020 Mar 25 [updated 2020 Mar 30; cited 2020 Apr 14].

2. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): Information for pediatric healthcare providers [Internet]. [place unknown]: CDC; [date unknown] [updated 2020 Apr 3; cited 2020 Apr 14].  

3. World Health Organization [internet]. World Health Organization; 2020. Guiding principles for immunization activities during the COVID-19 pandemic: interim guidance, 26 Mar 2020 [cited 2020 Apr 14].

4. Suk JE, Paez Jimenez A, Kourouma M, Derrough T, Baldé M, Honomou P, et al. Post-Ebola measles outbreak in Lola, Guinea, January-June 2015. Emerg Infect Dis [Internet]. 2016 Jun [cited 2020 Apr 14];22(6):1106-8.  

5. Delamou A, Ayadi AME, Sidibe S, Delvaux T, Camara BS, Sandouno SD, et al. Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study. Lancet Glob Health [Internet]. 2017 Apr [cited 2020 Apr 14];5(4):e448-e457.

​​

• Experts recommend that clinicians and parents begin by asking children what they understand about the COVID-19 pandemic, ensuring to correct any false information/beliefs that the child may have.(1,2,3,4) Simple, age appropriate explanations should be provided. In particular, children need explanations regarding the rationale for changes in their routines and structures. Any questions posed by children should be answered honestly with credible information. 

​

• Clinicians can recommend that parents: (1) teach their children when and how to wash their hands, (2) encourage them to do their part to flatten the curve, (3) limit their children’s consumption of COVID-19 related media, and (4) try to maintain a household routine while modeling healthy coping behaviours.(1,2,3,4)

​​

• Clinicians and parents should monitor children and teens for signs of anxiety and/or depression and seek professional assistance as needed, especially for children with pre-existing mental illness.(1,2) Resources for children’s mental health include: AbilitiCBT for 16+ years in Manitoba, and Kids Help Phone.

​

​

1. Dalton L, Rapa E, Stein A. Protecting the psychological health of children through effective communication about COVID-19. Lancet Child Adolesc Health 2020.  

2. Weaver MS, Wiener L. Applying Palliative Care Principles to Communicate with Children about COVID-19. J Pain Symptom Manage [PREPRINT]. 2020 

3. Canadian Pediatric Society. How can we talk to kids about COVID-19? Be “realistically reassuring” 2020. Accessed April 15, 2020.

4. Centers for Disease Control and Prevention. Talking with children about Coronavirus Disease 2019. 2020. Accessed April 15, 2020.

• In the current literature, laboratory abnormalities including lymphopenia are less common in children compared to adults.(1) In a systematic review of 66 children(2) and another study of 171 children(4), leukocyte counts were within normal range in 69.6%-73.7% of cases, with lymphopenia found in only 3.0-3.5%. The latter study also reported elevated procalcitonin in 64% of cases, but similar to adult patients, it is felt that this is most likely indicative of bacterial co-infection.

​​

• A small study of 36 children reported that lymphopenia, elevated procalcitonin, elevated D-dimer, and elevated CKMB had statistically significant association with moderate disease compared to asymptomatic or mild cases.(3) Leukocyte count, CRP, CK, and liver enzymes were abnormal in a minority of cases with no statistically significant relationship to illness severity.

​

​

1. Du W, Yu J, Wang H, Zhang X, Zhang S, Li Q, et al. Clinical Characteristics of COVID-19 in Children Compared with Adults Outside of Hubei Province in China. Rochester, NY: Social Science Research Network [preprint]; 2020.

2. Henry BM, Lippi G, Plebani M. Letter to the editor: Laboratory abnormalities in children with novel coronavirus disease 2019. Clinical Chemistry and Laboratory Medicine (CCLM) 2020;1.

3. Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. The Lancet Infectious Diseases 2020;1. PMID: 32220650.

4. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. SARS-CoV-2 Infection in Children. New England Journal of Medicine 2020.

​​

• Most cases of COVID-19 in children are mild, with only 0.6% of cases requiring admission to intensive care in a large Chinese case series.(1) Pediatric deaths are rare.(1,2)

​​

• To date, there is no literature specifically documenting the ICU management of pediatric patients with COVID-19. An expert consensus statement from China recommends early invasive mechanical ventilation with low tidal volumes to decrease ventilator-related lung injury.(3) They describe a two hours trial of non-invasive ventilation as acceptable, but providers should be cognizant that CPAP and BiPAP are aerosol-generating modalities and appropriate personal protective equipment is required.

​​

• In the absence of COVID-19-specific literature for severely ill children, consider the pediatric acute respiratory distress syndrome (ARDS) guidelines.

 

• At this time, there have been no recommendations for specific vasoactive medications or fluid consideration. 

​​

• National and local pediatric ICU guidelines for COVID-19 are currently being discussed. 

​

​

1. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics [Internet]. 2020 Apr 1 [cited 2020 Apr 8].

2. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. SARS-CoV-2 Infection in Children. New England Journal of Medicine [Internet]. 2020 Mar 18 [cited 2020 Mar 31].

3. Shen K, Yang Y, Wang T, Zhao D, Jiang Y, Jin R, et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts’ consensus statement. World J Pediatr [Internet]. 2020 Feb 7 [cited 2020 Mar 30].

4. Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med [Internet]. 2015 Jun;16(5):428–39 [cited 2020 Apr 8].

​​

• Disasters, including pandemics, can detrimentally impact the psychological well-being of children.(1,2) Clinicians should discuss this potential with pediatric patients and their families. Pandemics raise unique challenges due to physical distancing measures.

​​

• Previous research has shown that following a disaster, many children experience adjustment reactions, which include sleep and eating problems, depression, anxiety, concentration difficulties, substance abuse, and developmental or social regression. These symptoms may be more likely with separation from important caregivers and disruption in daily routines.(1)

​​

• A study of pandemic disasters that interviewed 398 parents found that of those who were quarantined or isolated, 33.4% reported that their children began using mental health services related to their experience. Common diagnoses were acute stress disorder, adjustment disorder, and grief. Children who experienced isolation or quarantine were more likely to meet criteria for PTSD based on parental report than those who did not (30% vs. 1.1%).(3)

​​

• In a small study, children 6 to 18 years old with probable or suspected SARS in 2003, reported feelings of sadness attributed to being alone, worrying about family members, and feelings of being punished while hospitalized and isolated from their caregivers.(4) Similarly, 21 children aged 5 to 19 years who were hospitalized during the period of strict infection control practices reported feeling isolated.(5) They also described feelings of anxiety, fear, and confusion related to a lack of information and conflicting messages about SARS.

​

​​

1. Schonfeld DJ, Demaria T, the Disaster Preparedness Advisory Council and Committee on Psychosocial Aspects of Child and Family Health. Providing psychosocial support to children and families in the aftermath of disasters and crises. Pediatrics [Internet]. 2015 Oct [cited 2020 Apr 08];136(4):e1120-30.

2. Bothe DA, Olness KN, Reyes C. Overview of children and disasters. J Dev Behav Pediatr [Internet]. 2018 Oct/Nov [cited 2020 Apr 08];39(8):652-662.

3. Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep [Internet]. 2013 Feb [cited 2020 Apr 08];7(1):105-10.

4. Koller DF, Nicholas DB, Goldie RS, Gearing R, Selkirk EK. Bowlby and Robertson revisited: the impact of isolation on hospitalized children during SARS. J Dev Behav Pediatr [Internet]. 2006 Apr [cited 2020 Apr 08];27(2):134-40.

5. Koller D, Nicholas D, Gearing R, Kalfa O. Paediatric pandemic planning: children's perspectives and recommendations. Health Soc Care Community [Internet]. 2010 Jul [cited 2020 Apr 08];18(4):369-77.

​​

• To date there has not been any published literature specifically examining the transmission risk of SARS-CoV-2 on playgrounds. As discussed in the 1st edition of the COVID-19 Report, in an experimental laboratory setting, SARS-CoV-2 virus particles can be found on steel and plastic for up to 72 hours.(1)

​

• Other respiratory viruses have been shown to spread via playgrounds.

​​

• A study in China investigated playgrounds as the reservoir for hand, foot and mouth disease (HFMD) outbreaks.(2) Enterovirus nucleic acid was detected on surfaces of several different playgrounds, suggesting possible transmission of virus when touched.

​​

• In a case-control study of preschoolers, playgrounds were associated with HFMD with a 57% attributable fraction.(3) The authors observed a dose-response relationship with the number of different playgrounds children attended.

​​

• As of Saturday, March 28, 2020, all public play structures in Winnipeg have been closed.(4)

​

​

1. Doremalen N van, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med [Internet]. 2020 Mar 17 [cited 2020 Apr 1].

2. Li P, Li T, Gu Q, Chen X, Li J, Chen X, et al. Children’s Caregivers and Public Playgrounds: Potential Reservoirs of Infection of Hand-foot-and-mouth Disease. Scientific Reports [Internet]. 2016 Nov 7 [cited 2020 Apr 1];6(1):1–6.

3. Xie YH, Chongsuvivatwong V, Tan Y, Tang Z-Z, Sornsrivichai V, McNeil EB. Important roles of public playgrounds in the transmission of hand, foot, and mouth disease. Epidemiology & Infection [Internet]. 2015 May [cited 2020 Apr 1];143(7):1432–41.

4. City of Winnipeg. City of Winnipeg COVID-19 Update #4 [Internet]. Winnipeg; 2020 Mar 27 [cited 2020 Apr 1].

​​

• In a Chinese national-wide case-series, illness severity ranged from asymptomatic infection to critical illness including ARDS and sepsis.(1) 10.5% of 379 infants with suspected COVID-19 developed severe-critical infections.

​​

• As of April 1, 2020, three infant deaths associated with COVID-19 have been reported.

​​

• Initial presentations may include non-specific symptoms such as temperature instability, poor feeding, lethargy, and emesis,(2,3) which can progress to predominantly respiratory symptoms including tachypnea, hypoxia, and cough.(4)

​​

• Duration of illness seems to correlate with disease severity: 4-5 days in mild cases,(2) and 10-20+ days in severe-critical cases.(4) 

​​

• All documented positive cases in infants and neonates are believed to be due to familial or caregiver transmission.(2,3)

​

​

1. Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. [PREPRINT] 2020. 

2. Zeng L, Xia S, Yuan W, et al. Research Letter: Neonatal early-onset infection with SARS-COV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China. JAMA Pediatrics. 2020. 

3. Wei M, Yuan J, Liu Y, et al. Research Letter: Novel coronavirus infection in hospitalized infants under 1 year of age in China. JAMA. 2020.

4. Sun D, Li H, Lu XX, et al. Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center’s observational study. World Journal of Pediatrics. 2020.

• A few small studies have shown that children can be co-infected with SARS-CoV-2 and other respiratory pathogens.(1,2,3,4) Co-infection rates ranged from 0 - 47%. 

​​

• The studies varied in which respiratory pathogens were tested, but most included Influenza A or B, and Mycoplasma.  

​​

• None of the studies specifically looked at clinical features that help differentiate between children with or without co-infections.

​​

Our takeaway message: 

​

• In children, co-infection with SARS-CoV-2 is possible and should be considered even when another respiratory pathogen has been found.

​

​

​

​

1. 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. Pediatric Pulmonology. 2020; 1-6.

2. Xu Y, Li X., Zhu B, et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nature Medicine. 2020.

3. Jiehao C, Jing X, Daojing L, et al. A case series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clinical Infectious Diseases. 2020.

4. 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. MedRxiv. [PREPRINT] 2020.

• To date, there is no laboratory evidence of vertical transmission of SARS-CoV-2 among pregnant women infected in the third trimester.

​​

• In a review(1) of published case series,(2,3,4,5,6) samples were obtained including placenta, amniotic fluid and umbilical cord blood from a combined total of 37 women with confirmed COVID-19 infection. Samples were also taken from a total of 29 neonates including oropharyngeal swabs, gastric secretions, urine, and feces. All the samples tested negative for SARS-CoV-2 by RT-PCR.

​​

• Breastmilk samples from 6 mothers with SARS-CoV-2 tested negative.(2)

​​

• These findings correlate with previous studies that demonstrated no evidence of vertical transmission of SARS-CoV and MERS-CoV.(7,8,9)

​​

• In one case series, 3 of 33 neonates born to mothers with COVID-19 became symptomatic and had nasopharyngeal and anal swabs positive for SARS-CoV-2 RT-PCR on days two and four of life.(10) The three neonates were all born by C-section. The authors postulate the possibility of vertical transmission, but there is not enough data to draw this conclusion.

​​

• Further studies are needed to investigate the possibility of vertical transmission of SARS-CoV-2.  Of all the neonates reported with SARS-CoV-2 so far, none have been critically ill.

​

1. Schwartz DA. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med. 2020.

2. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, 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(10226):809-15.

3. Liu W, Wang Q, Zhang Q, Chen L, Chen J, Zhang B, et al. Coronavirus Disease 2019 (COVID-19) During Pregnancy: A Case Series. Preprints [preprint] 2020.

4. Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr. 2020;9(1):51-60.

5. Wang X, Zhou Z, Zhang J, Zhu F, Tang Y, Shen X. A case of 2019 Novel Coronavirus in a pregnant woman with preterm delivery. Clin Infect Dis. 2020.

6. Zhang L, Jiang Y, Wei M, Cheng BH, Zhou XC, Li J, et al. [Analysis of the pregnancy outcomes in pregnant women with COVID-19 in Hubei Province]. Zhonghua Fu Chan Ke Za Zhi. 2020;55(0):E009.

7. Shek CC, Ng PC, Fung GP, Cheng FW, Chan PK, Peiris MJ, et al. Infants born to mothers with severe acute respiratory syndrome. Pediatrics. 2003;112(4):e254.

8. Mullins E, Evans D, Viner RM, O'Brien P, Morris E. Coronavirus in pregnancy and delivery: rapid review. Ultrasound Obstet Gynecol. 2020.

9. Schwartz DA, Graham AL. Potential Maternal and Infant Outcomes from (Wuhan) Coronavirus 2019-nCoV Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections. Viruses. 2020;12(2).

10. 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.

• Children seem to have milder presentations compared to adults.(1,2,3,4,5,6)

​​

• Most common symptoms are cough and fever, with nasal congestion, rhinorrhea, sore throat, and in some cases diarrhea. Some test positive and/or have findings on chest CT while remaining asymptomatic.(3,4,5,6,7,8)

​​

• There are limited reports of severe cases including acute respiratory distress syndrome and septic shock.(1)

​​

• Children with underlying illness may be at a higher risk for hospitalization and respiratory distress.(2) Small studies of children hospitalized with COVID-19 reported good short term prognosis(3,4,5) and an average length of stay of 12.9 days.(2)

​

​

​

1. Centers for Disease Control. Coronavirus Disease 2019 (COVID-19): Information for Pediatric Healthcare Providers. [cited 2020 March 19].

2. 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. Pediatric Pulmonology. 2020; 1-6.

3. Xu Y, Li X., Zhu B, et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nature Medicine. 2020.

4. Cai J, Xu J, Lin D, et al. A Case series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clinical Infectious Diseases. 2020.

5. Wang D, Ju XL, Xie F, et al. Clinical analysis of 31 cases of 2019 novel coronavirus infection in children from six provinces (autonomous region) of northern China. Zhonghua Er Ke Za Zhi. 2020.

6. [PREPROOF] Rodriguez-Morales AJ, Cardona-Ospina JA, Gutierrez-Ocampo E, et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Medicine and Infectious Disease. 2020.

7. Chan J F-W, Yuan S, Kok K-H, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus inducating person-to-person transmission: a study of a family cluster. The Lancet. 2020.

8. Kam K-Q, Yung CF, Cui L, et al. A well infant with coronavirus disease 2019 (CoVID-19) with high viral load. Clinical Infectious Diseases. 2020.

9. Chen, F., et al., First case of severe childhood novel coronavirus pneumonia in China. Zhonghua Erke Zazhi, 2020. 58(0): p. E005. Referenced by CDC https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html