|Year : 2020 | Volume
| Issue : 1 | Page : 12-16
SARS CoV-2 infection in children
Department of Nephrology, Yashoda Hospitals, Secunderabad, Telangana, India
|Date of Submission||19-Jun-2020|
|Date of Decision||09-Jul-2020|
|Date of Acceptance||26-Jun-2020|
|Date of Web Publication||20-Jul-2020|
Dr. Urmila Anandh
Department of Nephrology, Yashoda Hospitals, Secunderabad - 500 003, Telangana
Source of Support: None, Conflict of Interest: None
Limited data suggest that children often have mild and asymptomatic disease, but some do require hospitalization. In a report from China, of the total infections, 2.4% were children. Although most children infected with SARS-CoV-2 have either asymptomatic (4%), mild illness (51%), or moderate illness (39%), severe illness has been reported in 6% of pediatric cases. The incubation period is similar to that of adults. This article briefly outlines SARS CoV-2 Infection in Children.
Keywords: Bloodshot eyes, extrapulmonary complications, fever, SARS-CoV-2, skin rash, tachypnea
|How to cite this article:|
Anandh U. SARS CoV-2 infection in children. J Renal Nutr Metab 2020;6:12-6
| Introduction|| |
Since the first report of a viral pneumonia secondary to new coronavirus in December 2019 in Wuhan China, SARS-CoV-2 infections have spread worldwide and are now a pandemic. The infection is preferentially affecting adults with comorbidities, but children are not spared. This review looks at the various aspects of SARS-CoV-2 infection with an emphasis on the differences in the clinical presentation and management in children.
| Epidemiology|| |
At the time of writing, more than 6 million people have been affected by coronavirus 19 (COVID-19) infection., The majority of them have been adults with comorbidities such as hypertension, diabetes, chronic lung disease, obesity, and cancer., Limited data suggest that children often have mild and asymptomatic disease, but some do require hospitalization. In a report from China, of the total infections, 2.4% were children. The data from the United States of America show a incidence of 1.7% in all laboratory-confirmed cases. There is a slight predilection of boys getting infected (56.6%), but there are no increased infection rates in minority communities. The age ranged from 1 day to 18 years, with the median age of infected children being 7 years.
Severe illness was seen in about 6% of children and was more common in infants compared to older children. Even in the United States, the majority of hospitalized children (5%–20% of all admissions in various studies) were infants.
Most of the children picked up the infection in the family. Children have prolonged fecal excretion of the SARS-CoV-2 viral particles and can remain infective for a longer period of time.
| Clinical Features|| |
Although most children infected with SARS-CoV-2 have either asymptomatic (4%), mild illness (51%), or moderate illness (39%), severe illness has been reported in 6% of pediatric cases. The incubation period is similar to that of adults. The common clinical signs and symptoms of SARS-CoV-2 infection in children are given in [Table 1]. Some children may present with a rash.
|Table 1: Clinical signs and symptoms of SARS-CoV-2 Infection in children,|
Click here to view
About 29% of patients had tachypnea on admission, and about 42% had tachycardia. More than 2% of children had an oxygen saturation of <92% during their hospitalization.
Clinical and demographic features suggestive of severe disease are as follows:,
- Age younger than 3 months
- Persistent high fever for 3–5 days
- Extrapulmonary complications
- Poor mental response, lethargy, and disturbance of conscious level
- Coinfection with other viruses or bacteria.
Children with congenital heart disease, bronchial pulmonary hypoplasia, severe malnutrition, anemia, childhood malignancies, and other respiratory tract anomalies have a higher predilection for contracting severe disease.
Children from North America and Europe are increasingly coming to attention to health-care workers with a unique clinical syndrome mimicking Kawasaki's disease and/or toxic shock syndrome. This pediatric multisystem inflammatory syndrome (PMIS) presents as a hyperinflammatory state leading to shock and multiorgan failure.
PMIS is not considered to be contagious, and the clinical signs and symptoms of this unique presentation include:
- Fever that lasts more than 5 days and gets higher
- Severe abdominal pain, vomiting, or diarrhea
- Bloodshot eyes
- Skin rash
- Change in skin color, which can include becoming pale, patchy, or blue
- Difficulty feeding or too sick to drink
- Trouble breathing or quick breathing
- Chest pain or racing heart
- Confusion, irritability, or lethargy
- Swelling and redness in the hands and feet
- Redness or cracking in the lips or tongue
- Swollen lymph nodes in the neck.
These children have predominant extrapulmonary symptoms and often have abdominal lymphadenopathy in ultrasound studies. They also go on to develop myocarditis and subsequent shock. It is important that they are picked up early and treated.,
There is a strong temporal association between COVID-19 and PMIS. PMIS often develops after the COVID-19 infection is settling; hence, the COVID-19 reverse transcription-polymerase chain reaction test may come negative in these children.
The WHO criteria for the diagnosis of PMIS are given in [Table 2].
|Table 2: The WHO Criteria for the diagnosis of pediatric multisystem inflammatory syndrome|
Click here to view
| Laboratory and Imaging Studies|| |
The following laboratory abnormalities are noted in children:,
- Reduced white cell count, lymphopenia
- ↑ ESR ↑ C-reactive protein
- ↑ D-dimers
- ↑ levels of enzymes such as muscle and liver enzymes and lactate dehydrogenase
- Metabolic acidosis in critically ill children
- ↑ Procalcitonin (80% of children).1
Chest radiographs show the presence of bilateral peripheral and subpleural opacities and consolidation. Computed tomography often reveals bilateral ground-glass opacities and nodules. Consolidation with a halo sign is often seen in about half of the cases which may be typical in children with SARS-CoV-2 infection.
Other rare and atypical imaging findings include:
- Local patchy shadowing
- Bilateral patchy shadowing
- Interstitial abnormalities
- Unilateral ground-glass opacities and consolidation
- Bilateral peribronchial thickening and peribronchial opacities
- Multifocal or diffuse ground-glass opacities and consolidation without specific distribution.
The chest radiograph is often not recommended in asymptomatic individuals. A computed tomography scan is preferred in symptomatic children and as a follow-up investigation when the child recovers. Imaging findings of bilateral multilobar infiltration, pleural effusions, and rapid worsening are of concern.
| Renal Involvement in Sars-Cov-2 Infection|| |
Acute kidney injury (AKI) is usually seen in COVID-19-infected adults who are critically ill. In infected children, AKI is often seen in the context of severe illness, and there is literature to suggest that AKI secondary to SARS-CoV-2 infection has a distinct pathophysiology. Early fluid resuscitation and lung-protective ventilation may prevent the development of AKI in children.
Some children may present with proteinuria when seen in the outpatient department and may have to collapse glomerulopathy in their renal biopsy. The types of renal involvement in children with SARS-CoV-2 infection are mentioned in [Table 3].
| Sars-Cov-2 Infection in Children and Chronic Kidney Disease|| |
Chronic kidney disease (CKD) is a risk factor for severe and critical illness in adults. This may have a lesser impact on children; the underlying comorbidities that lead to CKD in adults are not common in children. Children who are on immunosuppression for their kidney diseases (transplantation, vasculitis, and nephrotic syndrome) have mild symptoms. According to the European Rare Kidney Disease Reference Network registry, only three children, as of now, have required ICU admission because of renal complications.
In nephrotic syndrome children, scant data exist about the impact of immunosuppression on the natural history of COVID-19 infection. It may be advisable to defer the use of rituximab until more information is available.
Children on maintenance hemodialysis (HD) have a higher risk of contracting the infection because of their frequent exposure with medical personnel. The guidelines for the prevention of infection in children on dialysis are similar to that of CDC guidelines for adult HD patients. Ultraviolet light disinfection for more than 30 min is recommended in pediatric dialysis units. Peritoneal dialysis effluent should be disinfected with bleach before it is flushed through the toilet drain.
Transplanted children are supposed to continue the same immunosuppression while maintaining the utmost precautions.
| Treatment|| |
Therapy recommendations in children are similar to that of adults. Most of them receive supportive fluid resuscitation and oxygen supplementation. In a study from the USA, 38% of the children were managed with invasive/tracheostomy ventilation. Antibiotics should be only used in children with bacterial coinfection. The underlying comorbidities of the children should be addressed and treated appropriately. AKI is mostly managed conservatively. Only a few children required dialytic therapies.
Drugs used in children included hydroxychloroquine and azithromycin. A few children received tocilizumab and remdesivir. Safety and efficacy of remdesivir have not been assessed in children. The pediatric dosing of the drug was based on pharmacokinetic data from adult volunteers. Many investigational immunotherapies and antivirals have been used in children with variable outcomes., The therapeutic options in children are given in [Table 4].
There are many candidate vaccines which are undergoing trials. None have been used in the clinical setting as yet.
| Nutritional Aspects of Sars-Cov-2 Infection in Children|| |
Viral infections are common in patients who have malnutrition, and hence adequate nutritional supplements play an important role in managing patients with SARS-CoV-2 infection. The craving for macronutrients during isolation is an important issue leading to micronutrient deficiency. It is important to have a balanced nutritional intake, which has a high quantity of minerals, vitamins, antioxidants. Diet rich in fruits (mangoes, lemons, oranges, strawberries, etc.) and vegetables (green leafy vegetables, potatoes, red peppers, broccoli, carrots, etc.) improve the immune system.
Vitamin C has been shown to prevent common cold and modify the severity of infection. A balanced diet comprising citrus foods may benefit children with COVID-19 infection. Another vitamin whose deficiency has been shown to exacerbate mortality in patients with respiratory infection is Vitamin D. Vitamin D also inhibits the cytokine storm in viral infections. Adequate supplementation should be instituted in the child's dietary plan. Zinc supplementation is also advised as it inhibits SARS coronavirus RNA-dependent RNA polymerase template binding and elongation in cultured respiratory epithelial cells.
A major issue is the delivery of nutrition to children admitted in the ICU. Often it is difficult to maintain oral nutrition in the child who is on ventilation. The constant change in position and prone ventilation often jeopardizes the Ryle's tube/infant feeding tube placement. Critically ill children on ventilation usually require parenteral nutrition. All efforts should be made to prevent malnutrition so that recovery is uneventful in ventilated children.
| Conclusions|| |
SARS-CoV-2 pandemic has ravaged humanity since the turn of this year. The disease has affected humans in more than 200 countries worldwide. The disease was initially believed to be milder in children. However, as our experience with the increases, we are realizing that the virus is also responsible for severe illness in the pediatric population. It has a unique manifestation in children which mimics Kawasaki's disease and needs a different therapeutic strategy.
AKI is relatively rare in children and is managed on similar lines as it is done in adults. Nutritional issues in children need to be addressed aggressively as they have a higher propensity for developing malnutrition.
Extreme care in preventing the infection remains to be our best strategy in children till we have a vaccine or effective drugs for the treatment of SARS-CoV-2 infection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al
. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.
Cai J, Xu J, Lin D, Yang Z, Xu L, Qu Z, et al
. A case series of children with 2019 novel coronavirus infection: Clinical and epidemiological features. Clin Infect Dis 2020;ciaa198. doi: 10.1093/cid/ciaa198. Online ahead of print.
Lu X, Zhang L, Du H, Zhang Z, Li YY, Qu J, et al
. SARS-CoV-2 infection in children. N
Engl J Med 2020;382:1663-5.
World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). World Health Organization; 2020.
CDC COVID-19 Response Team. Coronavirus disease 2019 in children United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422-6.
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al
. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet 2020;395:514-23.
Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for dengue. J Am Acad Dermatol 2020;82:e177.
Henry BM, Lippi G, Plebani M. Laboratory abnormalities in children with novel coronavirus disease 2019. Clin Chem Lab Med 2020;58:1135-8.
Wu Q, Xing Y, Shi L, Li WS, Gao Y, Pan S, et al
. Co-infection and other clinical characteristics of COVID19 in children. Pediatrics. 2020;doi: 10.1542/peds.2020-0961.
Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395:1607-8.
Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Segal JB, et al
. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr 2020;10:537-40.
Multisystem Inflammatory Syndrome in Children and Adolescents with COVID-19. Scientific Brief. World health organization; 2020.
Shen K, Yang Y, Wang T, Zhao D, Jiang Y, Jin R, et al
. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: Experts' consensus statement. World J Pediatr 2020;16:223-31.
Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults. Pediatr Pulmonol 2020;55:1169-74.
Foust AM, Phillips GS, Chu WC, Daltro P, Das KM, Garcia -Pena P, et al
. International expert consensus statement on chest imaging in pediatric COVID-19 patient management: Imaging findings, imaging study reporting and imaging study recommendations. Radiology: Cardiothoracic Imaging. epub 2020/4/23.
Battle D, Soler MJ, Sparks MA, Hiremath S, South Am, Welling PA, et al.
on behalf of the COVID 19 and ACE2 in Cardiovascular, Lung, Kidney Working Group. Acute kidney injury in COVID-19: Emerging evidence of a distinct pathophysiology. JASN 2020;31:1380-3.
Hossein EM. Renal Involvement in children with COVID -19 infection. J Renal Inj Prev 2020;9:e20.
Shen Q, Wang M, Che R, Li Q, Zhou J, Wang F, et al
. Consensus recommendations for the care of children receiving chronic dialysis in association with the COVID-19 epidemic. Pediatr Nephrol 2020;35:1351-7.
Shekerdemain LS, Mahmood NR, Wolfe KK, Briggs BJ, Ross CE, McKiernan CA, et al.
for the International COVID 19 PICU Collaborative. Characteristics and outcomes of children with coronavirus disease (COVID 19) infection admitted to US and Canadian pediatric intensive care units. J Pediatr. 2020;S0022-3476:30580-1. doi: 10.1016/j.jpeds.2020.05.006. Online ahead of print.
Ronco C, Reis T, Hussain Syed F. Management of acute kidney injury in patients with COVID 19. Lancet Respir Med. 2020;8:738–42. Published online 2020 May 14. doi: 10.1016/S2213-2600:30229-0 PMID: 32416769.
Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): A review. JAMA. 2020;323:1824-36.
Casadevall A, Pirofski LA. The convalescent sera option for containing COVID-19. J Clin Invest 2020;130:1545-8.
Chandra RK. Effects of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 1992;340:1124-7.
Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2013:CD000980.
Muscogiuri G, Altieri B, Annweiler C, Balercia G, Pal HB, Boucher BJ, et al
. Vitamin D and chronic diseases: The current state of the art. Arch Toxicol 2017;91:97-107.
te Velthuis AJ, van den Worm SH, Sims AC, Baric RS, Snijder EJ, van Hemert MJ. Zn (2+) inhibits coronavirus and arterivirus RNA polymerase activityin vitro
and zinc ionophores block the replication of these viruses in cell culture. PLoS Pathog 2010;6:e1001176.
[Table 1], [Table 2], [Table 3], [Table 4]