SCCM Resource Library-62-Patterns of COVID-19 Illness in Hospitalized Children

Video Transcription

Good afternoon, everyone. My name is Meghana Nadigar. I am one of the critical care fellows here at Nicholas Children's Hospital in Miami, Florida.  I'm going to be speaking about the patterns of COVID-19 illness in hospitalized children. No relevant disclosures.  Severe acute respiratory distress syndrome coronavirus 2, or SARS-CoV-2, is responsible for the COVID-19 pandemic.  It appears that COVID-19 primarily affects the respiratory system early in the course  of the disease and may include a late presentation involving inflammation and Kawasaki disease-like clinical features.  The objective of the study was to describe the patterns of clinical illness in hospital course of children admitted with COVID-19 to a tertiary care pediatric center.  Following approval by the Institutional Review Board, the charts of all children admitted and positive for SARS-CoV-2 RNA by RT-PCR and or SARS-CoV-2 antibodies IgG or IgM from  the plasma or those suspected as having MIS-C or the multisystem inflammatory syndrome in children as per the CDC case definition were reviewed.  Demographic and clinical characteristics, lab values, and therapeutic interventions were reviewed and are described here.  Statistical analysis was done using SPSS software version 25. Categorical variables are described as frequencies with chi-squared test or Fisher exact test used for comparison.  Various variables are described as median with interquartile range with Mann-Whitney U test used for comparison. A p-value less than 0.05 was considered statistically significant.  During the study period through June 30, 2020, approximately 4,400 children were tested in our ED.  Out of these, 2,400 were tested for clinical symptoms, approximately 1,700 for pre-surgical evaluation, and 137 children were tested prior to admission to inpatient psychiatry.  Out of the 2,400 tested for clinical symptoms, 17.4% were positive. That was an N of 417, and 68 children among these were admitted to the inpatient floors,  which was our study population. Out of the 68 admissions, 88% or 60 were PCR positive and were classified as having early disease.  12% were PCR negative but had positive serology or fit the epidemiological definition with recent exposure to someone with COVID-19.  Children positive by RT-PCR with any respiratory symptoms or signs or who required any form  of respiratory support were included in the pulmonary presentation group, and those symptomatic  children positive by RT-PCR but without pulmonary involvement were grouped into the non-pulmonary presentation.  It is important to note that children across both disease groups, that is early and late, fit the clinical case definition for MIS-C as per CDC criteria.  And both children in the early and the late groups had features of CKLD, but it was more frequent in the late group rather than the early group.  Overall, 72% of the children had mild to moderate illness, and 16% of the children had severe illness.  In this study, we've defined severe COVID-19 illness as any patient receiving one or more of the following supportive interventions, which could be respiratory support, which  is oxygen either via high flow nasal cannula or non-rebris or mask or invasive or non-invasive mechanical ventilation, patients receiving ECMO, patients on vasoactive medications or  on renal replacement therapy. COVID-related Kawasaki-like disease was seen in 13.2% of the patients.  Overall, 57% of the patients met the CDC case definition criteria for the multisystem inflammatory syndrome in children. Median age of the cohort was 6.4 years, and 46% were male.  85% of the population was Hispanic, with 84% white population, 8.8% black population, and 7.4% belonging to other races. This distribution reflects that of the local population.  38% had pre-morbid conditions. Asthma and diabetes were considered pre-morbid conditions. Any child over two years of age, we could calculate a BMI, and there were 45 such children.  89% of them were categorized as obese or overweight with a BMI above 25. Fever was the most common presenting symptom, which was present in 79.4% of all patients,  followed by respiratory symptoms in 60%, and GI symptoms as presenting symptoms in 47% of the patients. Three children in our inpatient cohort had anosmia.  The gastrointestinal system was the most common organ system involved, followed by the hematologic and the respiratory systems.  Cardiac involvement was seen in three quarters of the patients with severe illness, and 40% of MIS-C and CKLD patients.  Children with severe illness had more organ systems involved, as was expected. 72% of all hospitalized children and all children under the age of two years had mild to moderate  illness. These children were significantly younger than those with serious illness, and the gastrointestinal system was the most common organ system involved.  25% of the patients were admitted to the Pediatric Intensive Care Unit. All these children met criteria for MIS-C.  Majority had early disease with pulmonary manifestations requiring respiratory support, and eight children developed ARDS with an SF ratio of less than 264.  16% of the children had severe COVID-19 disease, based on the modalities of support as we had described earlier.  These children with serious illness were adolescents, with a BMI greater than 25 in 73% of them.  82% of them had pre-morbid conditions, and 72% of these children with severe COVID-19 developed ARDS.  These are the CDC criteria for the case definition for MIS-C. 39 children, or 57% in our cohort met the criteria for MIS-C diagnosis as per the CDC criteria.  The characteristics of children with MIS-C were compared to those without MIS-C. The distribution of gender, race, and ethnicity was similar.  However, we did find a significant difference in the age distribution. Children with MIS-C were significantly older, with a median age of about 10 years, compared  to those without MIS-C, who had a median age of about two years. Cardiac involvement was seen in 41% of the patients with MIS-C, compared to none in children without MIS-C.  Vasoactive medications were required in 10% of children with MIS-C, and an echocardiogram was performed in 39% of the children with MIS-C.  Coming to lab abnormalities, among hematologic abnormalities, lymphopenia and thrombocytopenia were more common in the MIS-C group, as were elevated D-dimers.  Inflammatory markers, including CRP-procal and ferritin, were higher in the MIS-C group. Hepatic dysfunction was more frequent, and cardiac enzymes were more frequently elevated  in the MIS-C group. All of these findings were statistically significant. We explored the performance of various lab tests in predicting MIS-C. We found that  at the thresholds specified here under, presence of one or more of lymphopenia or thrombocytopenia  or an elevated CRP or elevated D-dimers on admission or an elevated BNP had a sensitivity of 0.84 and a specificity of 0.75 for the diagnosis of MIS-C in COVID-19.  At these thresholds, the predictive accuracy or area under the curve was 0.8, and this finding was statistically significant.  Next we described the COVID-related Kawasaki-like disease. These children were 2 to 12 years old, non-obese with no premorbid conditions.  All of them fit the criteria for MIS-C, and very few of them were PCR positive, fitting the pattern of late disease, and they had very less frequent pulmonary involvement.  All of them had mucocutaneous involvement, and cardiac involvement was more frequent. They were treated with IVIG steroids and anticoagulation.  This slide shows the therapies that were used. Children with severe COVID-19 illness and CKLD required remdesivir and convalescent  plasma predominantly in the early forms of the disease, and IVIG steroids and anticoagulation across both the early and the late forms of the disease.  In conclusion, we observed three patterns of COVID-19 illness in hospitalized children. The first, a severe illness with respiratory involvement and obese adolescence, similar  to the adult disease. A Kawasaki-like disease with varying cardiac involvement in 2 to 12-year-olds.  Both of these fitting criteria for MIS-C, and a majority of our population had the third pattern, which was a mild to moderate illness in younger children, with children under 2  being generally spared from severe disease. This concludes my presentation, and I thank you all for your time.

Video Summary

The speaker, Meghana Nadigar, a critical care fellow at Nicholas Children's Hospital in Miami, discussed the patterns of COVID-19 illness in hospitalized children. The study reviewed the charts of children admitted with COVID-19 and examined their demographic and clinical characteristics, lab values, and therapeutic interventions. Out of the 68 admissions, 88% had early disease and 12% were PCR negative but had positive serology. 72% of the children had mild to moderate illness and 16% had severe illness. COVID-related Kawasaki-like disease was seen in 13.2% of the patients. The study also compared the characteristics of children with and without the multisystem inflammatory syndrome in children (MIS-C). Lab abnormalities and therapies used were also discussed. Overall, three patterns of COVID-19 illness were observed: severe illness with respiratory involvement in obese adolescents, Kawasaki-like disease with cardiac involvement in 2 to 12-year-olds, and mild to moderate illness in younger children.

Asset Subtitle

Pediatrics, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Meghana Nadiger, MD

Introduction/Hypothesis: The patterns and hospital course of COVID-19 in children appears distinct from adult experience and requires clear delineation. The objective of this study is to describe the clinical course of children admitted with COVID-19 to a tertiary care pediatric center and to evaluate the frequency of MIS-C in various COVID-19 illness patterns.

Methods: Children(68) admitted with COVID-19 till June 2020 were included in an IRB approved, retrospective single center study. Serious COVID-19 illness was defined as any child requiring invasive respiratory or cardiovascular support or renal replacement therapy. COVID-related Kawasaki-like disease(CKLD) was defined as any patient with COVID-19, fever â‰¥5d, elevated inflammatory markers and mucocutaneous lesions. Remaining patients were mild to moderate illness. CDC criteria were used to identify multisystem inflammatory syndrome in children (MIS-C).

Results: The median age was 6.4Y. 31(45.6%) were male. 60(88.2%) were positive for SARS-CoV-2. Eight cases were antibody positive or epidemiologically linked. MIS-C was present in 39(57.4%), serious COVID-19 illness in 11(16.2%), CKLD in 9(13.2%) and rest had mild to moderate illness(n=49;72%). MIS-C was present in all cases admitted to PICU(n=17) or who had severe illness and CKLD cases. Most common organs involved were hematologic(51.5%), hepatic(50%), respiratory(41.2%) and cardiac(23.5%). Children with serious illness were adolescents with elevated BMI(73%), premorbid conditions(82%) and ARDS(72%). Children with CKLD were 2-12 years old with no premorbid condition. Of PICU admissions, 11 needed supplemental oxygen, 6 non-invasive ventilation and 3 invasive ventilation. ARDS (S/Fâ‰¤264) was present in 8. The presence of lymphopenia, thrombocytopenia, CRP>3mg/dL, admission D-dimer>0.41Î¼g/mL or elevated BNP levels had a sensitivity of 0.84 and specificity of 0.75 for MIS-C diagnosis with COVID-19(AUC:0.80;95%CI:0.68-0.91;p<0.001).One child died.

Conclusions: The 3 patterns of COVID-19 in hospitalized children were (1)severe illness seen in obese adolescents with premorbidity (2)CKLD in 2-12 year-olds with varying cardiac involvement (3)mild to moderate illness in younger children. Children<2 years are generally spared from severe disease. MIS-C is present in all children with severe illness and CKLD.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Year 2021

Keywords

COVID-19 illness

hospitalized children

Kawasaki-like disease

MIS-C

lab abnormalities

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