GI Symptoms in Kids With COVID May Predict Severe Outcomes

Marcia Frellick

December 21, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Severe gastrointestinal (GI) involvement can be common in children who have had COVID-19, a new study shows.

Andrea Lo Veccio, MD, PhD, with the Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, in Naples, Italy, and colleagues retrospectively analyzed data from a large cohort of children aged 18 years and younger who had been diagnosed with COVID-19 between February 25, 2020, and January 20, 2021, in 54 Italian institutions.

Overall, 685 Italian children (56.4% boys; average age, 7 years) were included in the study. Of these, 628 (91.7%) were diagnosed with acute SARS-CoV-2 infection and 57 (8.3%) with multisystem inflammatory syndrome in children (MIS-C).

When children had GI symptoms, the authors found a higher risk of hospitalization (odds ratio [OR], 2.64; 95% CI, 1.89 – 3.69) and nearly four times the risk of intensive care unit (ICU) admission (OR, 3.90; 95% CI, 1.98 – 7.68).

Severe GI involvement occurred in 65 children (9.5%). The authors included the following within that category: disseminated adenomesenteritis (39.6%), appendicitis (33.5%), abdominal fluid collection (21.3%), pancreatitis (6.9%), or intussusception (4.6%). Additionally, out of these 65 children, 27 (41.5%) underwent surgery.

Older children were much more likely than preschoolers to have severe GI symptoms. Children aged 5–10 years were eight times more likely than preschoolers to show severe symptoms (OR, 8.33; 95% CI, 2.62 – 26.5). In those older than age 10 years, severe symptoms were six times more likely (6.37; 95% CI, 2.12 – 19.1).

Awareness about its frequency and presentation may help practitioners to appropriately manage children at risk of severe outcomes, the authors write.

The findings of this study were published online December 20 in JAMA Network Open.

Study Highlights the GI Link

Reached for comment, William Balistreri, MD, with the Division of Gastroenterology, Hepatology and Nutrition at Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio, said that it has been known that children are more likely than adults to present with GI symptoms, and also that these symptoms are especially common in children with MIS-C.

Dr William Balistreri

"The symptoms most commonly cited in the literature to date include diarrhea, nausea, vomiting, or abdominal pain," he said. "What [has not been known] is the frequency, predictive markers, and clinical course of the severe GI manifestations of COVID-19."

The findings of this study are important to clinicians to help recognize the potential for severe GI involvement, Balistreri said, adding that "the occurrence of abdominal pain, leukopenia, and elevated inflammatory markers or MIS-C should raise suspicion and lead to early evaluation."

Also weighing in was Margaret E. Thew, APNP, medical director in adolescent medicine and a family nurse practitioner with Medical College of Wisconsin in Milwaukee, who said that news reports typically emphasize the respiratory involvement, but this study provides a detailed analysis of the link between GI symptoms and COVID-19.

Margaret Thew, APNP

"Their data show that there may be less respiratory illness with children, regardless of whether they are generally healthy kids," she said. "They may have more GI symptoms.

"We know that COVID-19 causes a lot of inflammation, and a large percentage of these kids had inflammation in their stomach or an inflamed bowel," she added.

Thew said primary care doctors and urgent and emergency care clinicians will benefit from the findings of this study and should be on alert when kids come in with belly pain or vomiting.

Parents will benefit too, she said, if they are waiting for respiratory illness before they suspect COVID.

"You have to have a high suspicion this is going to be COVID-positive," she said. "You have to have that as part of your thought process."

Though the study was done in Italy, Thew added that their experiences mimic those she's seen locally.

Lo Vecchio reports fees from Pfizer as an advisory board member outside the submitted work. A co-author reports speaker's fees from Angelini, Sobi, and X4 Pharma outside the submitted work. No other disclosures were reported. Balistreri and Thew report no relevant financial relationships.

JAMA Netw Open. Published online December 20, 2021. Full text

Marcia Frellick is a freelance journalist based in Chicago. Follow her on Twitter at @mfrellick.

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