Pediatric Critical Care and COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, disproportionally affects adults (children 60 centers in nearly 20 countries from the Americas and Europe. In this report, we provide preliminary insights into our first 17 patients. Methods The Critical Coronavirus and Kids Epidemiology is a cohort study of children <19 years old with severe or critical COVID-19. The study period runs from April through December 2020. For this report, we included patients enrolled through April 23. We defined critical COVID-19 as a positive severe acute respiratory syndrome coronavirus 2 test result and requiring ICU therapies (high-flow nasal cannula [HFNC], noninvasive ventilation [NIV], invasive mechanical ventilation [IMV], vasoactive support, continuous renal replacement therapy). Severe COVID-19 included those receiving mask or nasal oxygen exceeding the pediatric acute respiratory distress syndrome (ARDS) “at risk” threshold.8 Deidentified data were collected by using a modification of the International Severe Acute Respiratory and Emerging Infection Consortium form (https://isaric.tghn.org/COVID-19-CRF/). Local ethics approval was obtained with a waiver of need for consent. Results We enrolled 17 children from 10 PICUs in Chile, Colombia, Italy, Spain, and the United States. Detailed data are in the Supplemental Information. Most patients were male (65%), young (median 4 years; range 0.08–18 years), and without known COVID-19 exposure (14 of 17). Comorbidities (Table 1, Supplemental Table 3) were common (71%) but variable. Symptoms were heterogenous, with fever and cough being most frequent (Table 1, Supplemental Table 3). Most with gastrointestinal (GI) symptoms (4 of 6) were also diagnosed with myocarditis (Supplemental Table 4). All these were from Europe and without previous cardiovascular disease

Estudio transversal analítico de las características y desenlaces clínicos de niños hospitalizados con COVID-19 en Lima, Perú

Introduction: Coronavirus 2019 (SARS-CoV-2) infection in children occurred in Peru as of March 2020, leading to pediatric patients' hospitalization in areas adapted for this purpose at the Edgardo Rebagliati Martins National Hospital. In the beginning, the demand for hospitalization was low, but it increased gradually. Consistent with international reports, the majority of patients presented mild or moderate symptoms. Nonetheless, there were also severe cases, even fatal ones. Objectives: To describe the characteristics and clinical outcome of pediatric patients with COVID-19 hospitalized in a referral hospital in Lima, Peru, between March and August 2020. Methods: A descriptive and inferential cross-sectional study was carried out. The population includes all hospitalized patients in the Department of Pediatrics, with clinical and surgical diagnoses associated with COVID-19. Results: We included 100 patients, with an average age of 83.4 ± 54 months, with a predominance of male patients (55%). Hospitalized patients were grouped into five categories: respiratory failure (17%), multisystemic inflammatory syndrome (MIS-C) (31%), neurological presentation (19%), acute abdomen (20%), and patients with oncological problems (13%). Most of the patients (74%) had comorbidities. Regarding the presenting symptoms, intestinal pain predominated in the appendicitis group (90%, p < 0.001), fever was present in most patients with respiratory failure (64.7%); multisystemic inflammatory syndrome (90.3%), neurological manifestations (15.8%), acute abdomen (50%) and oncological conditions (61.5%) were also present in these patients. Kawasaki symptoms were found in 38.7% of the patients with multisystemic inflammatory syndrome. Mortality was 4%. Respiratory problems (29.4%) and multisystemic inflammatory syndrome (22.6%) required admission to intensive care, more frequently than the other presentations (p = 0.008). Conclusions: We conclude that the vulnerability in the pediatric population is the one that has preexisting conditions. We divided our patients according to presentation, diagnosis, and complications, which were predominantly respiratory. We also had oncological patients with COVID-19.Introducción: La infección por coronavirus 2019 (SARS-CoV-2) en niños se presentó en Perú desde marzo del 2020. Desde entonces fue necesario internar pacientes pediátricos en el Hospital Nacional Edgardo Rebagliati Martins, en el área de hospitalización adaptada para dicho propósito. Al inicio, la demanda de hospitalización era baja y se fue incrementando progresivamente. Coincidiendo con los reportes internacionales, la mayoría presentó cuadros leves o moderados, pero también hubo casos graves e incluso mortales. Objetivos: Describir las características y el desenlace clínico de los pacientes pediátricos con COVID-19 hospitalizados en un hospital de referencia en Lima, Perú, entre marzo y agosto de 2020. Métodos: Se realizó un estudio transversal descriptivo e inferencial. La población incluyó a todos los pacientes que se hospitalizaron en el Departamento de Pediatría Clínica, con diagnósticos clínicos y quirúrgicos asociados a COVID-19. Resultados: Incluimos 100 pacientes, con edad promedio de 83,4 ± 54 meses, con predominio de varones (55%). Los pacientes hospitalizados fueron agrupados en cinco categorías: insuficiencia respiratoria (17%), síndrome inflamatorio multisistémico (31%), presentación neurológica (19%), abdomen agudo (20%) y pacientes con problemas oncológicos (13%). La mayoría de los pacientes (74%) tenían comorbilidades. Respecto a los síntomas de presentación, el dolor intestinal predominó en el grupo de apendicitis (90%, p < 0,001), la fiebre estuvo presente en la mayoría de los pacientes con falla respiratoria (64,7%), el síndrome inflamatorio multisistémico se registró en 90,3%, la sintomatología neurológica en 15,8%, el abdomen agudo 50% y oncológicos en 61,5% de los pacientes. Los síntomas de Kawasaki estuvieron presentes en 38,7% de los pacientes con síndrome inflamatorio multisistémico. La mortalidad fue de 4%. En 29,4% de problemas respiratorios y en 22,6% de síndrome inflamatorio multisistémico, se requirió de admisión en cuidados intensivos, lo que fue más frecuente que las otras presentaciones (p = 0,008). Conclusiones: Se concluye que la población pediátrica vulnerable es aquella con comorbilidades preexistentes. La división de pacientes en nuestro estudio fue definida por la presentación, diagnóstico y complicaciones predominantemente con problemas respiratorios, y en pacientes oncológicos con COVID-19.Revisión por pare

Epidemiology and Outcomes of Critically Ill Children at Risk for Pediatric Acute Respiratory Distress Syndrome:A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study

OBJECTIVES: Interventional trials aimed at pediatric acute respiratory distress syndrome prevention require accurate identification of high-risk patients. In this study, we aimed to characterize the frequency and outcomes of children meeting "at risk for pediatric acute respiratory distress syndrome" criteria as defined by the Pediatric Acute Lung Injury Consensus Conference. DESIGN: Planned substudy of the prospective multicenter, international Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study conducted during 10 nonconsecutive weeks (May 2016-June 2017). SETTING: Thirty-seven international PICUs. PATIENTS: Three-hundred ten critically ill children meeting Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We evaluated the frequency of children at risk for pediatric acute respiratory distress syndrome and rate of subsequent pediatric acute respiratory distress syndrome diagnosis and used multivariable logistic regression to identify factors associated with subsequent pediatric acute respiratory distress syndrome. Frequency of at risk for pediatric acute respiratory distress syndrome was 3.8% (95% CI, 3.4-5.2%) among the 8,122 critically ill children who were screened and 5.8% (95% CI, 5.2-6.4%) among the 5,334 screened children on positive pressure ventilation or high-flow oxygen. Among the 310 at-risk children, median age was 2.1 years (interquartile range, 0.5-7.3 yr). Sixty-six children (21.3%) were subsequently diagnosed with pediatric acute respiratory distress syndrome, a median of 22.6 hours (interquartile range, 9.8-41.0 hr) later. Subsequent pediatric acute respiratory distress syndrome was associated with increased mortality (21.2% vs 3.3%; p < 0.001) and longer durations of invasive ventilation and PICU care. Subsequent pediatric acute respiratory distress syndrome rate did not differ by respiratory support modality at the time of meeting at risk criteria but was independently associated with lower initial saturation:FIO2 ratio, progressive tachycardia, and early diuretic administration. CONCLUSIONS: The Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria identify critically ill children at high risk of pediatric acute respiratory distress syndrome and poor outcomes. Interventional trials aimed at pediatric acute respiratory distress syndrome prevention should target patients early in their illness course and include patients on high-flow oxygen and positive pressure ventilation

Characteristics of Severe Acute Respiratory Syndrome Coronavirus-2 Infection and Comparison With Influenza in Children Admitted to U.K. PICUs

Objectives: Severe acute respiratory syndrome coronavirus-2 affects adults disproportionately more than children. A small proportion of children with severe acute respiratory syndrome coronavirus-2 required admission to a PICU. We describe the nationwide U.K. PICU experience of severe acute respiratory syndrome coronavirus-2 infection during the first wave of the pandemic and compare this with the critical care course of the 2019 influenza cohort. Design: Prospective nationwide cohort study of characteristics of severe acute respiratory syndrome coronavirus-2–positive children. Data collection utilized routine Pediatric Intensive Care Audit Network and severe acute respiratory syndrome coronavirus-2–specific data. Setting: All U.K. PICUs. Patients: Children less than 18 years old, admitted to U.K. PICUs between March 14, 2020, and June 13, 2020, and a positive severe acute respiratory syndrome coronavirus-2 polymerase chain reaction. Children admitted to U.K. PICUs in 2019 with influenza provided comparison. Interventions: None. Measurements and Main Results: We identified 76 PICU admissions among 73 children with a positive severe acute respiratory syndrome coronavirus-2 polymerase chain reaction test. Prevalence of PICU admissions per million was 5.2 for children versus 260 for adults. Ten children (14%) were identified on routine screening. Seventeen children (23%) had pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. Seventeen (23%) had coinfections. Invasive ventilation was required in seven of 17 children (41%) with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 versus 38 of 56 other severe acute respiratory syndrome coronavirus-2 positive children (68%), with 77% requiring vasoactive support versus 43%, respectively. Seven children (10%) died. In comparison with influenza children, severe acute respiratory syndrome coronavirus-2 children were older (median [interquartile range]: 10 [1–13] vs 3 yr [1–8 yr]), more often Black or Asian (52% v 18%), higher weight z score (0.29 [–0.80 to 1.62] vs –0.41 [–1.37 to 0.63]), and higher deprivation index (3.3 [–1 to 6.3] vs 1.2 [–1.8 to 4.4]). Comorbidities, frequency of organ supports, and length of stay were similar. Conclusions: This nationwide study confirms that PICU admissions with severe acute respiratory syndrome coronavirus-2 infections were infrequent. We have reported similarities and differences in sociodemographic characteristics, organ support interventions, and outcomes of children affected by severe acute respiratory syndrome coronavirus-2 compared with influenza

Caracterização de uma população pediátrica de baixa renda vivendo acima de 2.500 m. s. n. m. positiva para SARS-COV-2

Infection with the new SARS-COV-2 has impacted the entire society, including children, in various ways. The behavior of this disease in a low-income pediatric population located above 2500 m. a. s. l. is described. This is a cross-sectional retrospective study carried out between March and October 2020 in Bogotá involving children between 1 month and 14 years old with positive rt-pcr for SARS-COV-2. History, sociodemographic, clinical, laboratory, radiological and evolutionary character- istics were studied, grouping the patients according to severity and analyzing their significance (p &lt; 0.05). As a result, 416 cases were obtained, of which 43.3 % were asymptomatic, 46.6 % mildly symp- tomatic, 8.9 % severe, and 1.2 % critical. Of the consultants to the emergency room, those under 1 year of age were the most frequent (56.79 %) and those who were hospitalized the most (35.8 %). The time between the onset of symptoms and consultation was an average of 2 days. The most frequent diagnosis in non-hospitalized patients was rhinopharyngitis (58.97 %), and in those who were hospitalized it was bronchiolitis (50 %). The median hospitalization time for the entire group was 4 days, which was extended to 7 days for those who required ICU. Hospitalization is associated with, among other causes, nutritional indices &lt; 2 SD, tachypnea, respiratory distress, hypoxemia, lymphopenia (in those older than 2 years) (p &lt; 0.05), with neither overcrowding nor socioeconomic status as influencing factors. After the study, it was possible to conclude that the disease is generally much milder among children than in adults, differing from these in predisposing factors, paraclinical factors, and evolution. However, some demographic, clinical and laboratory variables could be associated with greater severity in this population group.La infección por el nuevo SARS-COV-2 ha impactado de diversas maneras a toda la sociedad, incluidos los niños. Se describe el comportamiento de esta enfermedad en una población pediátrica de escasos recursos localizada por encima de 2500 m. s. n. m. Este es un trabajo retrospectivo transversal entre marzo y octubre de 2020 en Bogotá involucró niños entre 1 mes y 14 años con rt-pcr positiva para SARS-COV-2. Se estudiaron antecedentes, características sociodemográficas, clínicas, de laborato- rio, radiológicas y evolutivas, agrupando los pacientes según la gravedad y analizando su significancia (p &lt; 0.05). Como resultado, se obtuvieron 416 casos, de los cuales 43.3 % eran asintomáticos, 46.6 % sintomáticos leves, 8.9 % graves y 1.2 % críticos. De los consultantes a urgencias, los menores de 1 año fueron los más frecuentes (56.79 %) y los que más se hospitalizaron (35.8 %). El tiempo entre el inicio de los síntomas y la consulta fue en promedio de 2 días, El diagnóstico más frecuente en los pacientes no hospitalizados fue rinofaringitis (58.97 %), y en los que se hospitalizaron fue bronquiolitis (50 %). La mediana del tiempo de hospitalización de todo el grupo fue de 4 días la cual ser prolongó a 7 días para los que requirieron UcI. Con la hospitalización se asocia, entre otras causas, los índices nutricionales &lt; 2 DE, taquipnea, dificultad respiratoria, hipoxemia, linfopenia (en mayores de 2 años) (p &lt; 0.05), no influyendo el hacinamiento ni el nivel socioeconómico. Después del estudio, se pudo concluir que la enfermedad es, generalmente, mucho más leve en niños que en adultos, diferenciándose de estos tanto en los factores predisponentes, los paraclínicos y en la evolución. Sin embargo, algunas variables demográficas, clínicas y de laboratorio podrían asociarse con una mayor gravedad en este grupo poblacional.A infecção com o novo SARS-COV-2 impactou toda a sociedade de várias maneiras, incluindo crianças. O comportamento desta doença em uma população pediátrica de baixa renda localizada acima de 2.500 m. s. n. m. é descrito. Este é um estudo transversal retrospectivo entre março e outu- bro de 2020 em Bogotá, envolvendo crianças entre 1 mês e 14 anos com rt-pcr positiva para SARS-COV-2. Foram estudados antecedentes, características sociodemográficas, clínicas, laboratoriais, radiológicas e evolutivas, agrupando os pacientes de acordo com a gravidade e analisando sua sig- nificância (p &lt; 0.05). Como resultado, foram obtidos 416 casos, sendo 43.3 % assintomáticos, 46.6 % sintomáticos leves, 8.9 % graves e 1.2 % críticos. Dos pacientes em pronto-socorro, os menores de 1 ano foram os mais frequentes (56.79 %) e os que mais internaram (35.8 %). O tempo entre o início dos sintomas e a consulta foi em média de 2 dias, sendo o diagnóstico mais frequente nos pacientes não internados a rinofaringite (58.97 %), e nos internados foi a bronquiolite (50 %). A mediana do tempo de internação para todo o grupo foi de 4 dias, que foi estendida para 7 dias para aqueles que necessitaram de UTI. A hospitalização está associada, entre outras causas, a índices nutricionais &lt; 2 DP, taquipneia, desconforto respiratório, hipoxemia, linfopenia (nos maiores de 2 anos) (p &lt; 0.05), não influenciando a superlotação ou o nível socioeconômico. Após o estudo, foi possível concluir que a doença geralmente é muito mais branda em crianças do que em adultos, diferindo destes em fatores predisponentes, fatores para clínicos e evolução. No entanto, algumas variáveis demográficas, clínicas e laboratoriais podem estar associadas à maior gravidade nesse grupo populacional