Severe COVID-19 in Kids Rare With Variable Symptoms and Generally Good Outcomes

By Megan Brooks

August 07, 2020

NEW YORK (Reuters Health) - Critical pediatric COVID-19 disease is a rare entity with heterogeneous clinical presentation and generally good outcomes compared with adults, according to preliminary data from the Critical Coronavirus and Kids Epidemiology (CAKE) study.

CAKE is a prospective, multinational study collecting "granular epidemiological data" from 65 pediatric intensive-care units (PICUs) in 18 countries, Dr. Sebastian Gonzalez-Dambrauskas, with the Latin American Pediatric Collaborative Network (LARed Network), in Montevideo, Uruguay, told Reuters Health by email.

CAKE currently includes 26 sites in the U.S. and Canada, five in Europe, one in Asia and 33 in Latin America and the Caribbean.

In a new paper in Pediatrics, the study team provides preliminary insights into the first 17 children with severe or critical COVID-19 from 10 PICUs in Chile, Colombia, Italy, Spain and the U.S.

Critical COVID-19 is defined as having a positive SARS-CoV2 test result and requiring ICU therapies (high-flow nasal cannula, noninvasive ventilation, invasive mechanical ventilation, vasoactive support, continuous renal-replacement therapy). Severe COVID-19 included children receiving mask or nasal oxygen exceeding the pediatric acute respiratory distress syndrome (ARDS) "at risk" threshold.

Most of the children were male (65%), young (median, 4 years) and without known COVID-19 exposure (14 of 17). Comorbid conditions were common (71%) but variable.

Symptoms were heterogeneous, with fever and cough being most common. Children also frequently had gastrointestinal (GI) symptoms. Four of six children with GI symptoms were also diagnosed with myocarditis; none of these children had prior heart disease and all were from Europe.

Pediatric COVID-19 myocarditis has not been previously reported, although adult cases have been described. "Pediatric clinicians should consider cardiac involvement, particularly in those with the GI complaints common in our myocarditis patients," the researchers advise in their article.

Common laboratory findings in the 17 children included leukocytosis, lymphopenia, elevated inflammatory markers, D-dimer and troponin I.

Most of the children required respiratory support with nearly half requiring invasive mechanical ventilation.

Most of the children were treated with antibiotics; four received remdesivir. Corticosteroids, hydroxychloroquine, and tocilizumab were each prescribed to nearly half of the children. Intravenous immunoglobulin was given exclusively for myocarditis.

As an aside, Dr. Gonzalez-Dambrauskas said it's interesting that at participating centers in Latin America, where it is now winter, "we have seen a significant reduction in the number of infants and children with respiratory failure due to viral or bacterial infections other than COVID-19."

"Typically, during the winter our pediatric intensive-care units are filled with infants on ventilators due to bronchiolitis. We are working to understand why this is occurring as this may have implications for the remainder of winter in the Southern Hemisphere as well as the upcoming Northern Hemisphere winter," he said.

As of August 4, CAKE has enrolled almost 100 critical pediatric cases "and we are projecting perhaps 100 more by the end of 2020. It would all depend on the COVID-19 pandemic course, particularly in hotspots like Latin America where we have many CAKE centers," Dr. Gonzalez-Dambrauskas said.

SOURCE: Pediatrics, online August 5, 2020.