A total of 119 children (62 males, 52%; median age, 5.5; IQR 2; 10) were managed by the Hub Centre in the first month of activity (Figure). These included 90 children (mean age, 6 ± 4.1 years) managed in cooperation with FPs and 29 children (mean age, 6.9 ± 6 years) referred from other hospitals. A telephone call lasted a mean of 12 minutes and generally led to a shared decision between the experts within the Hub Centre and the family or hospital-based paediatricians. The main reasons for contacting the Hub Centre are reported in Table 2. At the beginning of the pandemic, most calls reflected a lack of knowledge and means to manage the resulting issues. In the subsequent phase, the reasons for calling became more specific. However, in many cases, the decisions and pathways for case management were not immediately clear. The major challenge was to make clear to the paediatricians calling that stopping the spread of infection was an issue as important to consider as a child’s clinical conditions.
Table 2. Reasons for telephone consultations and decisions taken
Type of request
|
Total cases
(n = 119)
|
Suspected cases
(n = 91)
|
Confirmed cases
(n = 28)
|
General information on how to manage a suspected COVID-19 child because of respiratory symptoms and fever, n (%)
|
79 (66)
|
79 (87)
|
0 (0)
|
Indications for microbiology examination, n (%)
|
42 (35)
|
41 (45)
|
1 (4)
|
Request for admission (general, not referring to clinical cases), n (%)
|
10 (12)
|
2 (2)
|
8 (29)
|
Indications for management of exposed children, n (%)
|
91 (76)
|
91 (100)
|
0 (0)
|
Management of COVID-19-positive children living with COVID-19-negative at-risk adults, n (%)
|
23 (19)
|
20 (22)
|
3 (11)
|
Request for admission (specific), n (%)
|
10 (12)
|
2 (2)
|
8 (29)
|
Prevention of infection (isolation/quarantine) generally, n (%)
|
119 (100)
|
91 (100)
|
28 (100)
|
Decisions taken following telephone consultations
|
Total cases
(n = 119)
|
Suspected cases
(n = 91)
|
Confirmed cases
(n = 28)
|
Management of a suspected case, n (%)
|
91 (76)
|
91 (100)
|
0 (0)
|
Management of a confirmed case, n (%)
|
28 (23)
|
0 (0)
|
28 (100)
|
Watchful waiting, n (%)
|
109 (92)
|
89 (98)
|
20 (71)
|
Isolation of a COVID-19-infected child where there was risk to a cohabitant, n (%)
|
3 (2)
|
0 (0)
|
3 (11)
|
COVID-19 triage, n (%)
|
12 (10)
|
12 (13)
|
0 (0)
|
Admission to the paediatric COVID-19 specialist unit, n (%)
|
12 (10)
|
2 (2)
|
8 (28)
|
The decisions taken are listed in Table 2. The most common decision was to reassure the paediatricians concerning the low risk of contracting COVID-19 in a child with respiratory symptoms and fever who had had no exposure to SARS-CoV-2. The availability of a follow-up call was reassuring to FPs; however, further contact rarely occurred and was uneventful in most cases. In certain cases, swabs were obtained, often because of the presence of cohabitants at risk of infection and where isolation at home might be required. It was decided in such cases that SARS-CoV-2 infection in the child (the suspected index case) needed to be confirmed or excluded to determine whether a cohabitant needed home isolation. However, delays in obtaining swab results was an operational barrier. Often these were available only after 12 to 36 hours, during which time preventive measures against infection had to be applied either at the home or in the hospital. Furthermore, the presence of at-risk persons living in the home was an indication to separate a suspected SARS-CoV-2-infected individual from non-infected individuals but often this was not possible at the home and the child needed to be taken to hospital to be isolated. Another issue was the unknown COVID-19 disease status among the cohabitants concerned, which necessitated a temporary separation of all members in the family or the application of preventive measures, where possible, while awaiting the microbiological results.
Often the clinical symptoms of SARS-CoV-2-infected children were mild and did not meet the criteria for hospitalisation. We aimed to limit unnecessary hospitalisation. In many cases, there was a specific request to hospitalise a child, because there was little or no knowledge of management options. In such cases, hospitalisation and infection prevention were discussed initially with the FP and subsequently between the FP and the family. Multiple members within the family were often found to be infected. When the caregiver from the family (often the mother) had to stay in the hospital with the child, discussion occurred on how to organise the family and each member’s role to find the best solution. Related to this, an issue for decision was the infection status of the person taking care of the child within the hospital isolation room, and this issue was openly discussed with the FP and by the FP in turn with the family before hospitalising the child. The caregiver had to be the mother, the father, or a relative, and that person was likely to be exposed or infected or at risk of becoming infected. The isolation room was organised as a mini-apartment, with food and hygiene products provided, and the caregiver was responsible for feeding and cleaning the child to limit contact with healthcare workers. In certain cases, parents with COVID-19 were cared for by relevant specialists. Approximately 50% of the children included in this series had had exposure to relatives who tested positive to COVID-19. A total of 8 children were hospitalised (median age, 2 years; range, 0.2–5 years; mean, 0.6 ± 2.1 years) with a median length of hospital stay of 10 days (IQR, 8.5 days; range, 4–22 days). Specific reasons for hospitalisation are listed in Table 3.
Table 3. Main reasons for hospital admission in children with confirmed SARS-CoV-2 infection
|
Patient 1
|
Patient 2
|
Patient 3
|
Patient 4
|
Patient 5
|
Patient 6
|
Patient 7
|
Patient 8
|
Age (years)
|
0.5
|
0.25
|
4
|
0.3
|
5
|
4
|
0.6
|
0.8
|
Sex
|
Male
|
Female
|
Female
|
Male
|
Female
|
Male
|
Male
|
Male
|
Overall clinical conditions
|
Moderate
|
Mild
|
Mild
|
Mild
|
Mild
|
Mild
|
Mild
|
Severe
|
Criteria for hospital admission
|
Infection spread prevention
|
Yes
|
No
|
No
|
Yes
|
Yes
|
No
|
No
|
No
|
Clinical hallmarks
|
Respiratory distress
Complex febrile seizure
|
-
|
Maculo-
papular rash
|
-
|
Maculo-
papular rash
|
Chest pain
|
Loss of appetite
|
Severe Sepsis
|
Risk factors
|
-
|
Prematurity
Grade 2-IVH*
Congenital cardiopathy
Congenital syphilis
|
-
|
-
|
-
|
-
|
-
|
-
|
Contact of at-risk cohabitants with a confirmed case
|
Brother with autism
|
-
|
-
|
Grandfather with cancer
|
Brother with severe congenital cardiopathy
|
-
|
-
|
-
|
*IVH, intraventricular haemorrhage
|
A 5-month-old boy (patient 1) was admitted with mild respiratory distress and had a relatively severe course of SARS-CoV-2 infection following a return of fever after a period of clinical improvement. He developed his first episode of complex febrile seizures, although a computed tomography CT scan of the head was negative, and had a long-lasting persistence of the virus, as shown on serial nasopharyngeal swabs (25 days). A 2-month-old preterm girl (born after 31 weeks of gestation, patient 2) with grade-II intraventricular haemorrhage, an atrial septal defect, congenital syphilis, and a previous episode of sepsis while in the neonatal intensive care unit, and who was admitted due to her age and concomitant risk factors, showed relatively mild respiratory symptoms. Two other patients (patients 4 and 5) presented with skin maculopapular lesions, but both patients had an uneventful disease course. Patient 6, who had a mild infection course at home, tested positive to SARS-CoV-2 infection, using a nasopharyngeal swab, following two consecutive negative test results, and was referred to the unit for chest pain. A 9-month-old boy (patient 8) was admitted with a diagnosis of COVID-19, acute diarrhoea, and severe sepsis. During hospitalisation, a blood culture tested positive for extensive beta-lactamase-producing Pseudomonas and the infant received appropriate antibiotic treatment, fluid support, and blood transfusion. No respiratory supportive care was needed. A major reason for hospital admission in 3 of the 8 children was to prevent the spread of infection.