key: cord-0715072-bu6093mh
authors: Al-Hajjar, Sami; McIntosh, Kenneth
title: Pediatric COVID-19: An Update on the Expanding Pandemic
date: 2020-05-18
journal: Int J Pediatr Adolesc Med
DOI: 10.1016/j.ijpam.2020.05.001
sha: 6eb82ea3add7d8fbfc7cd5d3d70a16b9d22e007f
doc_id: 715072
cord_uid: bu6093mh

nan

The coronavirus disease of 2019 (COVID-19) 1 is caused by a novel and highly contagious virus termed "Severe Acute Respiratory Syndrome Coronavirus Two," or "SARS-CoV-2". 2 The virus was first recognized in the city of Wuhan, China in December 2019 3 and has swept the globe at an unprecedented speed as a result of airline travel and sustained human-to-human transmission. The World Health Organization (WHO) declared COVID-19 a pandemic on March 11 th , 2020 due to the rapid increase in the number of cases and the wide geographical spread outside of China. 4 At the time of the announcement, the WHO estimated a global mortality rate of 3.4 percent. 5 Most of the fatal cases have occurred in patients with advanced age or with preexisting medical comorbidities, including cardiovascular diseases, diabetes, hypertension, chronic respiratory disease and cancer. 6 Currently over 4 million people have been infected, overwhelming global health systems and causing threats to health security. 7

Children of all ages are susceptible but have experienced a lower incidence of COVID-19 disease. Data from the Chinese Center for Disease Control and Prevention suggest that less than 1% of the 72,314 cases reported in China were in children under the age of 10 years, with a median age of approximately 7 years (range of 1-18 years). 6 Data from around 150,000 laboratory-confirmed COVID-19 cases in the United States indicate that 2,572 (1.7%) cases were among children under the age of 18 years. The median age for all infected children was 11 years (with a range from 0-17 years of age). 8 Males were more frequently infected than females in all pediatric age groups. Mortality was very unusual. 6, 8 The SARS-CoV-2 virus is transmitted mainly via respiratory droplets. 9 Nearly 90% of children with COVID-19 were believed to have been infected via close contact with family members or community exposure. 10 Current data indicate that infected children are not themselves a major source of transmission. This is in contrast to influenza, where children have played an important role in the transmission to household contacts and are important drivers of epidemics in the community. 11, 12 A very limited number of infections have been reported in infants and neonates. At the present time there is no evidence that SARS-CoV-2 is transmitted from mother to child during pregnancy. [13] [14] [15] Moreover, although the virus may be transmitted during birth or very shortly thereafter, this is unusual. 16 There is also currently no evidence that the virus is teratogenic, although, because of the small number of reported cases of infection during the first trimester (when embryogenesis occurs), a risk of congenital anomalies associated with COVID-19 cannot be completely excluded. 16 Data and prior experience with other respiratory viruses (e.g. influenza, SARS-CoV-1, MERS) suggest that antenatal transplacental transmission via maternal viremia is unlikely. 13 Analyses of amniotic fluid, serum, placenta, vaginal fluid and breastmilk from pregnant women confirmed to have COVID-19

infections have found no evidence of SARS-CoV-2 infections. 13 had neutropenia, and 3% reported lymphocytopenia. 23, 24 Lymphocytopenia was reported in more than 80% of critically ill adults with COVID-19 suggesting that the severity of Lymphocytopenia correlated with the severity of infection. 25 The low frequency of lymphopenia in children may be, at least in part, due to less severe COVID-19 encountered in children. C-reactive protein and procalcitonin were elevated in 13.6% and 10.6% of cases, respectively. 23 Elevation of liver enzymes, muscle enzymes and myoglobin, and an increased level of D-dimer have been reported in severe cases. 26 The radiological changes in the lungs of children with COVID-19 pneumonia have not been fully characterized. In a study of 171 children with PCRconfirmed COVID-19, 15.8% of patients' chest radiographs were read as normal. 18 Common computed tomography abnormalities in these children were bilateral ground glass opacities in 32.7%, local patchy shadowing in 18.7%, and interstitial abnormalities in 1.2 %. 18 In a study describing the CT scan findings for 20 SARS-CoV-2-infected children aged 1 day to 14 years 7 months (with a median of 37.5 months), 16 (80%) had abnormal lung CT scans, including consolidation with halo signs, ground-glass opacities and fine mesh shadow. 19 Chest CT imaging abnormalities may be present even in asymptomatic patients. 19 The few clear risk factors identified in children include age and underlying medical conditions. Among available data for 745 hospitalized children less China's CDC young children aged 1-5 years represented 7.3%, and this increased in infants less than 1 year of age to reach 10.6%. 17 The lower incidence of symptomatic and severely symptomatic COVID-19 in children compared to adults seems counterintuitive and is puzzling. There has been speculation that it could be due to children's younger immune systems and/or to a lower expression of ACE2 receptor cells. 27 testing. 34 This recommendation was subsequently endorsed by The Pediatric

Infectious Diseases Society. Hydroxychloroquine may be considered (with careful consideration of its potential toxicities, particularly those related to QTc prolongation) as an alternative to Remdesivir in countries where the latter drug is not available or the patient is not a candidate for Remdesivir.

There is a growing need for well-designed controlled clinical trials to better define the safety and efficacy of potential treatments for COVID-19 in children. Hopefully these trials can be completed over the next several months to allow us to provide the best treatment for children in this global pandemic.

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