A total of 208 children (109 males, 52.4%; median age, 5.2; IQR 2-9.6; range 2-15) with suspected COVID-19 were managed by the Hub Centre during the study period (Figure 1). These included 174 children (median age 5, IQR 1.5-9.6 years) managed in cooperation with FPs and 34 children (median age 3.75; IQR 0.4-12 years) referred from other regional hospitals. The main reasons for contacting the Hub Centre and related decisions taken are reported in (Table 1). One hundred-four patients (50%) received a final diagnosis of SARS-CoV-2 infection through RT-PCR on nasopharyngeal swab (Figure 1). Those children were managed either through telemedicine or hospitalization according to their clinical conditions, risk factors and respect of biocontainment measures.
Telemedicine
In our study population, most children showed mild-to-moderate clinical features, and the majority of children (74, 71.1%) were managed in telemedicine with FPs and caregivers.
A telephone call lasted 13 minutes in average and generally led to a shared decision between the experts within the Hub Centre and the paediatricians. At the beginning of the pandemic, most calls reflected a lack of knowledge and tools to manage the resulting issues. A major challenge emerging from the telephone consultations, was to make clear to the paediatricians that stopping the spread of infection was an issue as important to consider as a child’s clinical conditions. In the subsequent phase, the reasons for calling became more specific and centred on diagnostic and clinical issues.
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. However, delay in obtaining swab results (12-36 hours) was an operational barrier, mainly at the beginning of pandemic.
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. Biocontainment, defined as the risk of spreading SARS-CoV-2 infection to at-risk cohabitants in the absence of other isolation/quarantine measures, was included as a specific criterion for hospital admission. In four cases, when appropriate precautions were not realizable at home, children were taken to hospital to be isolated (Table 1).
Another issue was the unknown COVID-19 disease status among the cohabitants, which necessitated a temporary separation of all members in the family or the application of preventive measures, where possible, while awaiting the microbiological results.
Hospitalization
A total of 30 children were hospitalised (median age 1.15 IQR 0.5-4 years, range, 0.1–15 years) with a median length of hospital stay of 10 days (IQR 5-19 days; range 1–26 days). Specific reasons for hospitalisation are listed in (Table 2). In the majority of cases (14, 46.6%) the main indication to hospital admission was the presence of persistent fever, mild respiratory distress or co-infection occurring in infant or children with underlying conditions (Table 2). Notably, more than half of patients (16, 53.3%) aged below one year and 1 was a 23-days-old neonate, supporting the hypothesis that age was a common driver of hospital admission. None of our cases presented severe respiratory distress or needed oxygen support or ventilation. Four children (13.3%) presented a single episode of complex febrile seizures, in three cases the neurological presentation was the main reason for hospital admission (Table 2), and one infant admitted for fever and mild respiratory distress presented seizures during hospitalization. The latter showed no alteration to computed tomography CT scan, and a long-lasting persistence of the virus (25 days), as shown by serial nasopharyngeal swabs. A 9-month-old boy was admitted with a diagnosis of SARS-CoV-2 infection, acute diarrhoea, and the clinical feature of a 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 15-year-old girl, admitted for cough, showed a ground-glass pneumonia confirmed to CT scan and needed antibiotics and anticoagulant therapy with heparin.
The reasons for hospital admission slightly changed over time (Figure 2). Although the need of hospital procedures (i.e. intravenous rehydration, diagnostic work-up for trauma of suspected surgical conditions) or the presence of serious underlying conditions were equally distributed, we observed that during the first trimester of activity, about ¼ children was admitted for biocontainment. This criterion was not fulfilled from July 2020, reflecting the increase in the number of cases and a change in local COVID-19 epidemiology.
In many cases, we received by paediatricians a specific request to admit a positive 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 family members were often found to be infected. When the caregiver (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 the family before admitting the child. 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, SARS-CoV-2 infected parents were cared for by relevant specialists.