Critically ill children with SARS-COV-2 Omicron infection at a national children medical center, Guangdong, China

doi:10.21203/rs.3.rs-3769731/v1

Background

SARS-CoV-2 infection is described as asymptomatic, mild, or moderate disease in most children. SARS-CoV-2 related death in children and adolescents is rare according to the current reports. COVID-19 cases increased significantly in China during the Omicron surge, clinical data regarding pediatric critical patients infected with the omicron variant is limited. In this study, we aim to provide an overview of the clinical characteristics and outcomes of children admitted to the Pediatric Intensive Care Unit (PICU) at a national children's medical center in Guangdong Province, China, during the outbreak of the omicron variant infection.

Methods

We conducted a retrospective study from November 25, 2022, to February 8, 2023, which included 63 critically ill children, under the age of 18, diagnosed with SARS-CoV-2 infection. The patients were referred from medical institutions of Guangdong province. The medical records of these patients were carefully analyzed and summarized.

Results

During the study period, 63 children were included. The median age was 2 years (IQR: 1.0–8.0), sex-ratio (male/female) was 1.52. Twelve patients (age ≥ 3 years) were vaccinated. The median length of hospital stay was 14 days (IQR: 6.5–23) and duration of fever was 5 days (IQR: 3-8.5). 30 cases had clear contact history with family members who were infected with SARS-CoV-2. Three children who tested positive for COVID-19 infection did not show any abnormalities on chest imaging examination. Out of the total patients, 33 had a bacterial co-infection, with Staphylococcus aureus being the most commonly detected bacterial pathogen. Our cohort exhibited respiratory and nervous system involvement as the primary features. Furthermore, 50 patients required mechanical ventilation, with a median duration of 7 days (IQR 3.75–13.0). Among these patients, 35 developed respiratory failure, 16 patients experienced a deteriorating progression of symptoms and ultimately succumbed to the illness, with multiple organ failure being the attributed cause of death.

Conclusion

We present a case series of critically ill children infected with the SARS-CoV-2 omicron variant. While there is evidence suggesting that Omicron may cause less severe symptoms, it is important to continue striving for measures that can minimize the pathogenic impact of COVID-19 infection in children.

Critical ill children

SARS-CoV-2

Omicron variant

Bacterial co-infection

Nervous system

The emergence of the SARS-CoV-2 Omicron variant (B.1.1.529) in South Africa on November 9, 2021 marked the onset of a rapid global spread of the virus. The Omicron genome has given rise to a distinct monophyletic lineage, distinguished by the presence of over 30 mutations in the spike protein. As a result, the virus exhibits heightened affinity for human cells, leading to increased infection rates and evasion of the immune response [1, 2]. China implemented 'zero COVID' strategies since August 2021 to combat SARS-CoV-2 infections. Chinese government has continuously adjusted and optimized epidemic prevention and control policies to reflect the evolving situation in 2022. With gradual relaxation of policies, the number of individuals infected with SARS-CoV-2 has continued to rise. By the end of 2022, the SARS-CoV-2 Omicron outbreak was spreading relentlessly throughout China. Due to the heightened transmissibility of the SARS-CoV-2 Omicron variant, there has been a significant surge in hospitalizations, placing a strain on healthcare systems. Notably, there has been a substantial increase in hospitalizations of children infected by the Omicron variant during this period. While severe illness from COVID-19 is rare in pediatric patients, most cases in children present milder symptoms compared to infected adults, such as fever, cough, rhinorrhea, diarrhea, nausea/vomiting, or an asymptomatic state [3–5]. From December 8, 2022, to January 2023, an epidemic of the Omicron strain also occurred in Guangdong, China. There have been no detailed reports on Omicron variant infections of severe or critical cases among children following this outbreak. Guangzhou Women and Children's Medical Center, a national tertiary hospital for children in Guangdong Province, China, has been actively treating a large number of sick children, including referrals from other medical institutions. In this report, we present a series of critical cases of children with SARS-CoV-2 Omicron infection, which contributes to our understanding of the severe form of COVID-19 in children.

Study design and patients

We conducted a retrospective study at a national children's medical center in Guangdong, China, between November 25, 2022, and February 8, 2023. The study encompassed all children under the age of 18 who were critically ill and diagnosed with COVID-19. These children tested positive for SARS-CoV-2 nucleic acid in nasal and/or oropharyngeal swabs, and their diagnoses were supported by a combination of clinical manifestations and imaging findings observed during their hospitalization. We followed the disease severity classification provided by the World Health Organization (WHO) and the "New coronavirus pneumonia diagnosis and treatment protocol (Trial Version 10)" issued by the China National Health Commission to determine the severity of the cases [6, 7]. In summary, critical cases were defined as those meeting at least one of the major criteria, which include patients requiring mechanical ventilation for respiratory failure, patients requiring vasoactive medications for septic shock, or patients experiencing other organ failure that necessitates monitoring and treatment in the intensive care unit (ICU). Moreover, patient files were reviewed to identify cases of multisystem inflammatory syndrome in children (MIS-C) based on the diagnostic criteria of WHO [8].

Data collection

We conducted a comprehensive review of the medical records for all critically ill children who were admitted to the hospital during the study period and diagnosed with confirmed COVID-19 infection using RT-PCR testing. The patients' data encompassed various aspects, including demographic information, medical history, symptoms and signs, complications, laboratory findings, radiology examinations, treatment interventions, the need for ventilator support, and occurrence of adverse events. The clinical outcomes of interest were classified as either cured/discharge or mortality. Additionally, we also documented the vaccination status of the patients and the RT-PCR results for SARS-CoV-2 in the parents of the affected children..

Laboratory confirmation

We performed RNA extraction on nasal swab and/or oropharyngeal swab samples, followed by testing for the presence of SARS-CoV-2 viral RNA using an in-house Taqman RT-real-time PCR assay. The assay specifically targeted the N and ORF1ab genes, in accordance with the manufacturer's protocol [9].

Discharge criteria

The clinical condition was stable and the symptoms and signs disappeared.

Data analysis

All statistical analyses were conducted using SPSS 21.0 software. Descriptive statistics were employed to summarize all variables. Categorical data were expressed as number (n) and percentages (%), while continuous data were presented as either means and standard errors or medians and interquartile ranges (IQR).

Ethical considerations

This study adhered to the ethical guidelines outlined in the Declaration of Helsinki and was approved by both the Institutional Review Board of Guangzhou Women and Children's Medical Center (No.81801905) and Chaozhou Central Hospital (No.2023016). Given the retrospective nature of the study, the requirement for signed informed consent from participants or their guardians was waived.

Demographic data and clinical characteristics

From November 25, 2022, to February 8, 2023, a total of 63 children who tested positive for SARS-CoV-2 PCR required intensive care at the Pediatric Intensive Care Unit (PICU). Among these children, the median age was 2 years (interquartile range [IQR]: 1.0-8.0 years) and the sex ratio was 1.52 (38 males/25 females). A majority of the patients (39, 61.9%) were under 3 years old, and 24 cases were above 3 years old, twelve of them had received one or two doses of the COVID-19 vaccine.

The median length of hospital stay for the patients was 14 days (IQR: 6.5-23), and the median duration of fever was 5 days (IQR: 3-8.5). 30 cases had a positive contact history with a family member who had been infected with SARS-CoV-2. Additionally, nine children had underlying diseases, with six of them having epilepsy, one with nephrotic syndrome, and one with cerebral palsy. What’s more, one patient had acute myeloid leukemia and had undergone hematopoietic stem cell transplantation.

All patients in our cohort experienced at least one complication. The most prevalent complications were respiratory failure (35 cases, 55.6%) and encephalopathy (44 cases, 69.8%). Septic shock and epilepsy occurred in 22 (34.9%) and 10 (15.9%) patients, respectively. During hospitalization, 38 critical ill patients developed MIS. Unfortunately, sixteen patients experienced worsening of symptoms and ultimately succumbed to the illness, with multiple organ failure identified as the main cause of death.

Laboratory and radiological findings

Laboratory test results revealed reduced lymphocyte counts in 36 cases (58.1%) at admission. Elevated levels of procalcitonin (PCT), interleukin-6 (IL-6), and D-dimer were observed in 87.3%, 87%, and 88.9% of cases, respectively. Additionally, elevated levels of aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) were noted in 66.1% of cases during hospitalization (Table 2).

In terms of bacterial co-infections, 47 cases were tested for sputum bacterial culture

and 33 cases were confirmed. The most commonly detected bacterial pathogen was Staphylococcus aureus (16 patients), followed by Enterobacter species (4 patients), Haemophilus influenzae, Streptococcus pneumoniae, and Klebsiella pneumoniae (3 patients each). Other bacteria detected include Pseudomonas aeruginosa (2 patients) and Moraxella catarrhalis (one patient). Additionally, one patient tested positive for Tropheryma whipplei in a sputum sample through microorganism next-generation sequencing (mNGS).

Regarding respiratory virus co-infections, eight common respiratory viruses (Flu virus A and B, Parainfluenza virus, Respiratory syncytial virus, Rhinovirus, Adenovirus, Epstein-Barr virus and Bocavirus) were tested in throat swabs from 49 suspected cases by PCR assay. There were only 3 cases with additional respiratory viral infections (Epstein-Barr virus, Adenovirus, and Bocavirus, respectively).

Among the 56 patients who underwent chest CT or X-ray scans, most of the patients exhibited at least one abnormal chest imaging manifestation, such as bronchopneumonia, unilateral or bilateral pulmonary inflammation, pleural effusion, and pulmonary consolidation. Three patients showed no abnormalities on chest CT (Table 2).

A total of 37 pediatric patients underwent cranial CT or MRI examinations. Of these, 18 had no abnormalities detected within the cranium, while 19 were found to have intracranial abnormalities. Among the 19 cases, 6 were diagnosed with acute necrotizing encephalopathy (one patient had a history of epilepsy), 1 was diagnosed with acute disseminated encephalomyelitis, 4 were diagnosed with encephalitis, 1 was diagnosed with autoimmune encephalitis, 1 was diagnosed with reversible posterior brain syndrome, and 1 was diagnosed with reversible splenial lesion syndrome of the brain. In addition, 5 cases had other types of abnormalities (Supplemental Table 1).

The 6 cases of acute necrotizing encephalopathy presented with bilateral thalamic and bilateral basal ganglia symmetric hypodense lesions, or bilateral frontal lobe white matter hypodensity, or multiple abnormal signals within the brain. Among these cases, 2 were comatose within 2 days of onset, 4 exhibited seizures, 4 had a fever with a temperature ≥40℃, and 4 cases resulted in death.

Treatment and prognosis

None of the patients received any antiviral drug therapy (Paxlovid). Out of the total patients, fifty-one were initially treated with antibiotics (administered orally and intravenously) which was discontinued once bacterial infection was ruled out or cured. Additionally, corticosteroid therapy was administered to thirty-eight patients.

All patients required respiratory support, with fifty of them being placed on mechanical ventilation. The median duration of mechanical ventilation was 7 days (IQR 3.75–13.0). Sixteen patients experienced a deterioration in symptoms and ultimately succumbed to the illness, the main cause of death in these cases was attributed to multiple organ failure.

The prevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is particularly high among pediatric populations, especially during the Omicron variant waves. As of January 1, 2023, data from an open-access database of COVerAGE, revealed that children and adolescents under 20 years of age accounted for 21% of reported COVID-19 cases across 105 countries. Among these cases, 63% occurred in adolescents aged 10 to 19 years, while 37% occurred in children aged 0 to 9 years [10]. Evidence so far seems to indicate that intensive care admission, and deaths remained low in children with Omicron infection [11, 12]. During this outbreak, 63 children with life-threatening forms of SARS-COV-2 infection were admitted to Guangzhou Women and Children's Medical Center, sixteen deaths occurred among them.

Co-infection poses a serious complication for COVID-19, and we observed that thirty-three cases had bacterial co-infections, with twenty-two patients experiencing septic shock and seven deaths. Bacterial co-infections among children with COVID-19 may increase mortality rates. Recent multicenter, retrospective cohort studies have reported that COVID-19 bacterial co-infections are major risk factors for mortality, ICU admission, and mechanical ventilation [13]. An observational study in Taiwan revealed that the incidence rate of bacterial co-infections among hospitalized children with COVID-19 was 14.9% during the Omicron pandemic [14]. Detecting co-infected pathogens is important, however, most patients with suspected secondary infections may not have undergone thorough microbiological investigations during the pandemic. In our study, the most commonly detected bacterial co-infection pathogen was Staphylococcus aureus, followed by Escherichia coli, Haemophilus influenzae, Streptococcus pneumoniae, and Klebsiella pneumoniae, which are similar to the common causes of bacterial infection in influenza patients [15, 16]. Laboratory test results also offer valuable insights for patients suffering from COVID-19 and concurrent bacterial co-infections. Elevated levels of PCT were observed in most patients with bacterial co-infections in our cohort. As the patients recovered, their PCT levels returned to normal, aligning with findings from other studies highlighting the predictive role of PCT in bacterial co-infection among severe and critical COVID-19 patients [17–19], although the exact association between PCT levels and co-infections or mortality in COVID-19 is not fully elucidated.

In this study, acute liver injury and myocardial damage occurred in many patients, characterized by abnormal biochemical parameters such as mild to significantly elevated levels of serum ALT (28/62, 45.2%), AST (41/62, 66.1%), LDH (41/62, 66.1%), and CK (29/62, 46.8%). The cause is likely multifactorial, involving contributions from cytokine storm, inflammation, and drug toxicity.

While COVID-19 primarily affects the respiratory system, numerous neurological symptoms have been reported. Some symptoms, like loss of smell or taste, are mild and non-life-threatening, while others, such as seizures, are more critical [20, 21]. Neurological involvement in COVID-19 is consistently associated with worse outcomes, including ICU admission and mortality [22]. In the GCS-NeuroCOVID study, a large multicenter international study comprising over 3500 patients from three separate cohorts, 80% of the participants reported experiencing some form of neurological manifestation, with encephalopathy being the most common [23]. In the present study, we noted that 30 patients experienced encephalopathy, the cause is likely multifactorial that resulting from hypoxia–ischemia, cytokine storm, sepsis, metabolic derangement, electrolyte disturbances, medication effects, ICU delirium and a possible role for other immune mechanisms and endotheliopathy. Further studies are needed for establishing a definitive association of such symptoms with COVID-19 and also for a better comprehension of the underlying pathophysiological mechanisms.

Acute necrotizing encephalopathy (ANE), often occurs after infection with influenza virus and human herpesvirus type 6 [24–25], but cases of ANE caused by infection with the SARS-CoV-2, especially the Omicron variant, have also been reported [26]. The typical clinical features of ANE include a short-term fever following viral infection, which then progresses rapidly to acute encephalopathy, seizures, impaired consciousness, and eventually coma. In addition to acute encephalopathy, severe cases are often accompanied by multiple organ dysfunction, disseminated intravascular coagulation (DIC), and hemophagocytic lymphohistiocytosis syndrome [27]. ANE associated with COVID-19 infection has a rapid onset and progression, often leading to death or severe neurological sequelae. Early recognition and treatment are particularly important. Febrile seizures induced by COVID-19 infection are relatively common, and some children may not exhibit typical features of simple febrile seizures [28]. In this study, 66.7% (4/6) of the ANE patients had febrile seizures, characterized by generalized tonic-clonic seizures, with 2 cases presenting as status epilepticus. In the remaining 2 cases without seizure activity, rapid onset of altered consciousness occurred, progressing quickly to coma. Therefore, when children infected with the novel coronavirus present with high fever or hyperpyrexia and show neurological manifestations within a short period of time, ANE should be considered as a potential concern.

Many studies have shown that healthy children are at low risk of severe COVID-19 complications, very few children died of COVID-19 and most deaths were of children with other serious medical conditions [3, 4, 5, 10]. However, among the sixteen deaths in our cohort, only two patients had underlying diseases, specifically epilepsy and chronic myeloid leukemia. The notable being the majority of deaths were attributed to complications, such as multiple organ failure. These findings suggest that even children without underlying diseases can also experience severe or critical cases of COVID-19.

This study was conducted retrospectively at a single center in China. While the sample size may not be large enough, it still provides valuable additional data on critically ill children hospitalized in the Pediatric Intensive Care Unit (PICU) during the Omicron wave. The data collected in our study contributes to enhancing our understanding of the impact of COVID-19 on children.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval were granted by the Institute Ethics Committee of Guangzhou Women and Children Medical Center ((No.81801905) and Chaozhou Central Hospital (No.2023016), clinical data were collected by pediatricians, laboratory data were reviewed by the clinical laboratory staff.

Availability of data and materials

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Conflict of interest statement

The authors have no relevant financial or non-financial interests to disclose.

Author contributions

LY conceived the study and revised the manuscript. The manuscript was written by FL. DJ, SZ and HZ performed the clinical practices and data collection. ZY and ZL analyzed the data. All authors contributed to the article and approved the submitted version.

Acknowledgment: Not Applicable.

Funding sources

This work was supported by Special Research Plan 2019 of Chaozhou (2020xg01), Scientific Research Project of Chaozhou city (2023ZC01), and High Level Development Plan of People’s Hospital of Yangjiang (G2020007). The funder had no role in the study’s design, data interpretation, and manuscript writing.

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Table 1 Demographic and clinical features of critically hospitalized children with SARS-COV-2 Omicron infection

Characteristics	Critical COVID-19 Omicron infection (n = 63)
Age, years at admission (median, IQR)	2 (1.0-8.0)
<3	39 (61.9)
≥3	24 (38.1)
Sex
Male	38 (60.3)
Female	25 (39.7)
Length of hospital stay, day (median, IQR)	14 (6.5-23.0)
Vaccination（age≥3 years)*	12 (19)
One dose	3 (0.25)
Two dose	9 (0.75)
Contact history with family members
Yes	30 (47.6)
Unclear	31 (52.4)
Signs and symptoms ^a
Fever	58 (92.1)
Fever ≥39°C	45 (71.4)
Duration of fever days (median, IQR)	5 (3-8.5)
Cough	34 (54.0)
Hemoptysis	3 (4.8)
Dyspnea	20 (31.7)
Diarrhea	18 (28.6)
Hematochezia	4 (6.3)
Vomiting (coffee-like substance)	4 (6.3)
Convulsion	30 (47.6)
Laryngeal edema	3 (4.8)
Hepatomegaly	15 (23.8)
Splenomegaly	9 (14.3)
Rash	8 (12.7)
Neurological symptoms and signs ^b	37 (58.7)
Underlying disease
Epilepsy	6 (9.5)
Cerebral palsy	1 (1.6)
Nephrotic syndrome	1 (1.6)
Acute myeloid leukemia	1 (1.6)

Table 1 Demographic and clinical features of critically hospitalized children with SARS-COV-2 Omicron infection (Cont.).

Characteristics	Critical COVID-19 Omicron infection (n = 63)
Complications ^c
Respiratory failure	35 (55.6)
Pneumorrhagia	5 (7.9)
Encephalopathy	44 (69.8)
Heart failure	3 (4.8)
Septic shock	22 (34.9)
Convulsion	10 (15.9)
Renal failure	2 (3.2)
Hepatic failure	2 (3.2)
Disseminated intravascular coagulation (DIC)	1 (1.6)
Severe erythema multiforme	1 (1.6)
Multiple organs failure	11 (17.5)
MIS-C ^d	38 (60.3)
Oxygen supplementation
Mask oxygen inhalation/nasal prong oxygen	11 (17.5)
Mechanical ventilation	52 (82.5)
Duration of mechanical ventilation, day (median, IQR)	7 (3.8–13.0)
Medical treatment
Antibiotic	51 (81.0)
Corticosteroids	38 (60.3)
Immunoglobulin and other blood products	56 (88.9)
Vasoactive drugs	40 (63.5)
Medication for gastrointestinal diseases	18 (28.6)
Antiallergic drugs	5 (7.9)
Outcomes
Improve/discharge	47 (74.6)
Death in hospital	16 (25.4)

Data are n (%) except for age, length of hospital stay and duration of fever days; IQR: interquartile range.

^a Multiple presenting features were possible.

^bNeurological symptoms and signs: includes consciousness disorders, language disorders, motor disorders, etc.

^cMultiple complications were possible.

^dMIS-C: multisystem inflammatory syndrome in children.

Table 2. The main laboratory results and radiological findings.

	Critical Omicron infection (n=63)
Laboratory finding	Mean ± SE	Median (IQR)
Leucocyte count (×10⁹/L)	8.03±0.73	6.20 (3.88-11.20)
Reduced	19/62 (30.6%)
Elevated	13/62 (21.0%)
Lymphocyte (×10⁹/L)	2.29±0.33	1.56 (0.79-2.90)
Reduced	36/62 (58.1%)
Hemoglobin (g/L)	108±3.54	105 (89-128)
Reduced	34/62 (54.8%)
Platelet (×10⁹/L)	205±15.51	200 (104-290)
Reduced	26/62 (41.9%)
C-reactive protein (mg/L)	31.00±6.87	7.08 (1.38-30.04)
≥8	28/61 (45.9%)
Procalcitonin (ng/mL)	16.72±3.28	5.85 (0.19-22.75)
≥0.10	48/55 (87.3%)
Interleukin-6 (ng/L)	609.13±255.35	41.32 (10.23-407)
>7	20/23 (87%)
D-dimer (ug/mL)	8.20±2.23	2.96 (1.18-15.88)
≥0.50	24/27 (88.9%)
Alanine aminotransferase (U/L)	201±108.46	37 (18-110)
Elevated	28/62 (45.2%)
Aspartate aminotransferase (U/L)	303±91.00	75 (45-229)
Elevated	41/62 (66.1%)
Lactose dehydrogenase (U/L)	842±132.92	503 (314-831)
Elevated	41/62 (66.1%)
Creatine kinase (U/L)	713±211.66	220 (108-515)
Elevated	29/62 (46.8%)
Creatine kinase-MB (U/L)	32.9±10.04	5.2 (2.9-23.8)
Elevated	15/62 (24.2%)
Creatinine (umol/L)	67±18.96	31 (24-68)
Elevated	19/62 (30.6%)
Bacterial co-infection Co-infection of other respiratory virus	33/55 (60%) 3/49 (6.1%)
Abnormal chest imaging finding	53/56 (94.6%)
Pleural effusion	4/56 (7.1%)
Bilateral pulmonary diffuse inflammation/ Pulmonary consolidation	29/56 (51.8%)

Elevated means over the upper limit of the normal range and reduced means below the lower limit of the normal range.

Normal range are presented as below.

Leucocyte count, 0≤age<6m: 4.3-14.2 (×10⁹/L), 6m≤age<1y: 4.8-14.6 (×10⁹/L), 1y≤age<2y: 5.1-14.1 (×10⁹/L), 2y≤age<6y: 4.4-11.9 (×10⁹/L), 6y≤age<13y: 4.3-11.3 (×10⁹/L), 13y≤age<18y: 4.1-11.0 (×10⁹/L); Lymphocyte, 0≤age<6m: 2.4-9.5 (×10⁹/L), 6m≤age<1y: 2.5-9.0 (×10⁹/L), 1y≤age<2y: 2.4-8.7 (×10⁹/L), 2y≤age<6y: 1.8-6.3 (×10⁹/L), 6y≤age<13y: 1.5-4.6 (×10⁹/L), 13y≤age<18y: 1.2-3.8 (×10⁹/L); Hemoglobin, 0≤age<6m: 97-183 (g/L), 6m≤age<1y: 97-141 (g/L), 1y≤age<2y: 107-141 (g/L), 2y≤age<6y: 112-149 (g/L), 6y≤age<13y: 118-156 (g/L), 13y≤age<18y: male 129-172 (g/L), female 114-154 (g/L); Platelet, 0≤age<6m: 183-614 (×10⁹/L), 6m≤age<1y: 190-579 (×10⁹/L), 1y≤age<2y: 190-524 (×10⁹/L), 2y≤age<6y: 188-472 (×10⁹/L), 6y≤age<12y: 167-453 (×10⁹/L), 12y≤age<18y: 150-407 (×109/L); C-reactive protein, <8.00 (mg/L); Procalcitonin, <0.10 (ng/mL); Interleukin-6, 0-7 (ng/L); D-dimer: <0.50 (ug/ml); Alanine transaminase, 0≤age<1y: 8-71 (U/L), 1y≤age<2y: 8-42 (U/L), 2y≤age<13y: 7-30 (U/L), 13y≤age<18y: male 7-43 (U/L), female 6-29 (U/L); Aspartate transaminase, 0≤age<1y: 21-80 (U/L), 1y≤age<2y: 22-59 (U/L), 2y≤age<13y: 14-44 (U/L), 13y≤age<18y: male 12-37 (U/L), female 10-31 (U/L); Lactose dehydrogenase: 0≤age<1y: male 0-248 (U/L), female 0-247 (U/L), 1d≤age<1m: male 125-735 (U/L), female 145-765 (U/L), 1m≤age<1y: male 170-450 (U/L), female 190-420 (U/L), 1y≤age<13y: male 155-345 (U/L), female 165-395 (U/L), age≥13y: male 120-290 (U/L), female 100-275 (U/L); Creatine kinase, 0≤age<1d (U/L), 1d≤age<5d: 26-700 (U/L), 5d≤age<6m: 26-330 (U/L), 6m≤age<13y: 26-229 (U/L), age≥13y: 26-174 (U/L); Creatine kinase-MB, 0-24 (U/L); Creatinine, 0≤age<2y:13-33 (umol/L), 2y≤age<6y: 19-44 (umol/L), 6y≤age<13y: 27-66 (umol/L), 13y≤age<16y: male 37-93 (umol/L), female 33-75 (umol/L); 16y≤age<18y: male 52-101 (umol/L), female 39-76 (umol/L).

No competing interests reported.

SupplementalTable1.docx

Critically ill children with SARS-COV-2 Omicron infection at a national children medical center, Guangdong, China

Status:

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Abstract

Background

Methods

Results

Conclusion

INTRODUCTION

METHODS

Study design and patients

Data collection

Laboratory confirmation

Discharge criteria

Data analysis

Ethical considerations

RESULTS

DISCUSSION

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1