key: cord-0049399-sdn0olyk authors: Ng, SM title: COVID‐19 and children with diabetes: emerging knowledge date: 2020-08-15 journal: nan DOI: 10.1002/pdi.2289 sha: ccbcd0dc274f4013dd4da283bbf7a1d1e6aa03b2 doc_id: 49399 cord_uid: sdn0olyk The global epidemiological and clinical patterns of COVID‐19 among children with diabetes are still very limited. In this report Associate Professor May Ng investigates the current outcome data for young people with diabetes and COVID‐19 and discusses the need for continued vigilance to ensure emergency paediatric conditions are dealt with urgently, as well as the essential health messages for young people with diabetes. In March 2020, the World Health Organization declared the corona virus disease 2019 (COVID19) outbreak a pandemic and a public health emergency of international concern. A study of 1099 patients from China with laboratory confirmed symptomatic COVID19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS CoV2) reported that the most com mon symptoms of COVID19 were fever and cough, with a median incu bation period of four days. 1 Emerging research has now reported that the clinical spectrum of COVID19 can be very variable from mild flulike symptoms, to rash, blood disorders, pneumonia, acute respiratory distress syndrome (ARDS), respiratory fail ure, cardiac conditions, multiple organ failure and death. 2, 3 A systematic review of 45 relevant scientific papers reported that chil dren accounted for between 1-5% of confirmed COVID19 cases, and children presented with a milder disease course and better prognosis compared to adults. Deaths were also extremely rare in children. 4 Most of the studies reported origi nated from China, with a few from Italy, Iran and South Korea. The review included case reports of chil dren with COVID19 who had other comorbidities but was unable to identify any study that quantified the prevalence of comorbidities in children. The largest cohort of paediatric COVID19 cases were reported by Dong et al. based on the Chinese Center for Disease Control and Prevention epidemiological study of 2143 children under 18 years of age. In this study, one death was reported and 5.9% of the cases were categorised as severe and critical cases in children. 5 Early evidence reports that chil dren and young people have lower susceptibility and transmission rates of COVID19. 6 Somekh et al. reported that children age 5-17 years were 61% and children of 0-4 years of age were 47% less likely to have a COVID19 positive test compared with adults residing in the same household. 7 This was sim ilarly reported in populationbased screening studies in Iceland where children under 10 years of age had a lower incidence of COVID19 infection, 8 and in Geneva where significantly lower seroprevalence rates of infection were observed for children aged five to nine years. 9 Recent reports in the United Kingdom, United States of America, France and Italy citing a link between COVID19 and a type of Kawasakilike multisystem hyperin flammatory syndrome, also referred to as Paediatric Inflammatory Multi system Syndrome temporally associ ated with SARSCov2 (PIMSTS), has been especially worrying to parents. 10 Kawasaki disease is one of the most common known primary vasculitis disorders in childhood, typically occurring in children under the age of five. While the majority of children recover com pletely after a few weeks, early treatment is necessary to prevent possible severe complications such as coronary artery aneurysms. 11 SARSCoV2 is thought to affect multisystem organs through a com bination of direct vascular and proinflammatory activation which occurs during an acute COVID19 infection or post infection. 12 The relationship of Kawasaki disease to COVID19 remains unclear and causality has not been confirmed. People with diabetes are at risk of infections including influenza and are recommended to have the annual influenza vaccinations. 13 Diabetes remains a significant risk of morbidity and mortality in patients with COVID19. [14] [15] [16] Of 72,314 cases of COVID19 published by the Chinese Center for Disease Control and Prevention, an increase in mor tality in people with diabetes was found (2.3% overall compared with 7.3% in patients with diabetes). 14 National diabetes and mortality data in England reported a total of 17,882 and 372,242 deaths between 1 January 2017 and 24 April 2020 in people with type 1 and type 2 diabetes respectively. 17 This was the first and largest study to investigate the risk of mortality in hospital with COVID19 by type of diabetes. Barron et al. reported that onethird of all deaths inhospital with COVID19 occur in people with diabetes. After adjusting for key confounders such as age, sex, deprivation, ethnicity and geographi cal region, people with type 1 and type 2 diabetes had 3.50 and 2.03 times the odds respectively of dying in hospital with COVID19 compared to those without diabetes. The degree of hyperglycaemia measured by HbA1c and obesity in both type 1 and type 2 diabetes is also independently associated with increased COVID19 mortality. 17 At the time of writing, current global reports suggest that children, ado lescents, and young adults under the age of 25 years affected by type 1 diabetes have a disease pattern simi lar to that of children who do not have diabetes and are at no greater risk of being affected by COVID19 than those without diabetes. 19, 20 The International Society of Pediatric and Adolescent Diabetes (ISPAD) further reported that, as of 24 March 2020, paediatric endo crinologists from China and Italy reported no cases of COVID19 in youths with diabetes less than 25 years old requiring hospitalisation. 20 This was in concordance with the national diabetes and mortality data in England which reported no deaths of people with COVID19 and diabetes in the age group under 20 years old. 17 This was similarly reported in the United States where, out of 2572 COVID19 confirmed cases in people age 18 years and younger, documented comorbidi ties information did not include either type 1 or type 2 diabetes. 21 The global lockdown has reported on substantial reductions in paedi atric emergency attendances as well as visits to the general practi tioners in many countries, includ ing the United Kingdom. Children continue to become unwell with illnesses such as sepsis, chest infec tions, newlydiagnosed diabetes, severe asthma and surgical emer gencies such as appendicitis that are not COVID19 related. However, delayed access to seeing hospital care has been reported due to the fear of COVID19. 22, 23 Cases of delayed presentation leading to delayed diagnosis of newonset type 1 diabetes have been reported that led to presentation of severe diabetic ketoacidosis, a lifethreat ening condition. Reasons for delayed presentation have ranged from fear of contracting COVID19 to an inability to contact/access a medical provider for timely evalua tion. 23 It is critically important to stress that paediatric conditions will continue to occur and that fear and concerns of COVID19 should not be a reason to delay a referral or access to a health care provider. Due to fear of COVID19, there has been reduced access to primary care, diagnostics and hospital ser vices for many services including diabetes care. Many resources have been implemented to maintain a level of routine diabetes care through the use of social media, telemedicine and telephone clin ics. 24, 25 In paediatric diabetes, health care delivery has been at the forefront of transitioning towards remote care where clinical manage ment and structured education are now being delivered through tech nologyenabled approaches. 25 As the rules for access to telemedicine have become more relaxed, families and patients with diabetes are now collaborating with diabetes teams to upload data relating to their diet, physical activity data, blood glucose data and insulin pump data so that they can be reviewed together through telemedicine clinics, shared platforms and feedback given at the same time. Structured education and mental health support are being delivered remotely with good feedback. 25 In a future where the COVID19 pandemic is over, it is likely with the success of these meas ures that telemedicine and remote diabetes clinic management will become part of a routine form of delivering diabetes care. The global epidemiological and clinical patterns of COVID19 among children with diabetes are still very limited. While no definite conclu sions can be made based on the current evidence, there is emerging knowledge from research that would hopefully provide us with a better understanding of the associations between COVID19 and diabetes in children. More studies in children with diabetes and COVID19 are likely to have an impact on future recommendations. • The research and data on COVID-19 and children with diabetes are extremely limited • Limited evidence suggests that children and young people have lower susceptibility and transmission rates of COVID-19 • At present, there is no evidence to suggest that children with diabetes are more prone to being infected with COVID-19 compared to other children without diabetes • There is also no evidence that children with diabetes are more likely to be infected with COVID-19 paediatric multisystem inflammatory syndrome compared to children without diabetes • It is important that children with diabetes continue to be vigilant, especially around handwashing and social distancing • Children and families should follow the principles of management of diabetes sick days rules if they are unwell and be advised not to delay access or attendance of health care provisions • Children and families are encouraged to continue maintaining a healthy lifestyle and to optimise their diabetes management Clinical characteristics of coronavirus disease 2019 in China Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirusinfected pneumonia in Wuhan, China Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China Characteristics of hospitalized pediatric COVID-19 cases The role of children in the dynamics of intra family coronavirus 2019 spread in densely populated area Spread of SARS-CoV-2 in the Icelandic population Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study COVID-19 and Kawasaki disease in children Diagnosis, treatment, and long-term management of Kawasaki disease: A scientific statement for health professionals from the American Heart Association SARS-CoV-2-induced Kawasaki-like hyperinflammatory syndrome: A novel COVID phenotype in children Clinical considerations for patients with diabetes in times of COVID-19 epidemic Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China COVID-19 infection in Italian people with diabetes: Lessons learned for our future Practical recommendations for the management of diabetes in patients with COVID-19 Type 1 and type 2 diabetes and COVID-19 related mortality in England: a whole population study Type 1 and type 2 diabetes and COVID-19 related mortality in England: a cohort study in people with diabetes Coronavirus infection (COVID-19) -II ISPAD Summary Summary of recommendations regarding COVID-19 in children with diabetes: Keep Calm and Mind your Diabetes Care and Public Health Advice Coronavirus Disease 2019 in Children -United States Delayed access or provision of care in Italy resulting from fear of COVID-19 Unintended consequences of COVID-19: Remember general pediatrics The Australian response to the COVID-19 pandemic and diabetes -lessons learned COVID-19, type 1 diabetes, and technology: why paediatric patients are leading the way