COVID19 is a global health crisis. To our knowledge, this is the largest, in-patient pediatric COVID19 study from pediatric multispecialty public hospital in India. The study highlights the demographic features, clinical characteristics, disease progression, and outcome of 123 children admitted with COVID19. As this study enrolled children who were admitted to the hospital, the data likely represents individuals from the moderate to severe end of the disease spectrum.
As soon as the first pediatric COVID19 case was reported in March 2020, in Mumbai, a dedicated COVID care area, personnel, equipment, and protocol were organised on an emergency mode. Global data suggested that children were infected early during community transmission phase and hence a low threshold of suspicion was followed for COVID 19 testing. As the pandemic rapidly evolved and emerging evidence suggested that children were largely asymptomatic or mildly symptomatic, we adopted screening for SARS-CoV-2 in all admissions as the entire city had become a hotspot. In the initial few months, COVID19 cases were only from Mumbai. As the lockdown was slightly relaxed, more children from the Mumbai Metropolitan Region were admitted.
Of 969 children admitted, RT-PCR for SARS-CoV-2 was performed in 964. Of these, 123 tested positive, a positivity rate of 12.7% lesser than the reported overall positive rate of 20.8% until 7 August 2020.
There were 76 (62%) cases in Group I comprising of previously healthy children and 47 (38%) in Group II who had underlying illness. (Figure 2) In an earlier study from Columbia Pediatric COVID19 management group co-morbidities were defined as Obesity, Asthma, Infancy or Immune suppression were studied .
Median age of presentation was 3 years, older children (>10 years of age) were more in Group II. Twenty seven (21.7%) children were asymptomatic. Initial studies from China reported 4.1–50% cases to be asymptomatic, while 58% were asymptomatic in a study from Pune[2- 4]. The wide variation could be attributed to the difference in COVID19 testing protocol.
As seen in other series, fever and respiratory symptoms were the common presenting symptoms[8-10,12,13]. Atypical presentations like seizures (10.6%) and gastrointestinal symptoms (12.2%) were more common as compared to other studies.[7,9,12,14] Seizure and diarrhea as presenting symptoms was more common in Group I.
COVID19 disease severity characterization revealed mildly symptomatic children were significantly more in Group I (n = 50/76, 66%) than Group II (n = 4/47, 8.5%; p = 0.0001) and moderate to severe COVID19 was significantly more in Group II (n = 22/47, 47%) than Group I (n = 4/76, 5.3%; p = 0.0001). Children with an underlying illness had severe disease. Interestingly, the immunological consequence of COVID19, the MIS-C/KD (n = 11/123; 9%) was found more in Group I (n = 8/76, 10.5%) than Group II (n = 3/47, 6.4%). Interestingly, presence of co morbidity, dysregulates or blunts the immunological host responses causing severe infection but is unable to mount a hyperinflammatory immune response like MIS-C/KD.
Though chest radiograph is not considered the best modality to diagnose COVID19 pneumonia and unilateral or bilateral peripheral shadows and/or ground glass opacities have been described but pleural effusion is rare. In this series, 12 cases had consolidation/bilateral haziness and 7 had pleural effusion.
Thirty-nine (32%) cases needed intensive care. Severe COVID19 pneumonia, circulatory collapse, MIS-C/KD, and worsening of underlying disease were the common indications. Need for intensive care in our series is higher than reported in literature. This could be because we had more vulnerable children with underlying illness and severe COVID19 disease requiring intensive care. Although adult studies suggest presence of co-morbidities as an important predictor of need for intensive care[17,18], this was not found in our study. Children requiring mechanical ventilation (15.5%) were fewer than those in the cohort from USA [7, 19] which could be due to more children non respiratory presentations. There was no significant difference between the two groups with regard to length of hospital stay or disease outcome. (Table II)
A systematic review in adults concluded that co-morbidities like Hypertension, Cardiovascular disease, Diabetes, and chronic renal diseases were significantly associated with mortality . A study of children from the European cohort concluded that neonates, male sex, pre-existing medical conditions, fever, lower respiratory tract infection, radiological changes of pneumonia or ARDS, and viral co-infection were associated with more severe course on univariate analysis; however, the study did not compare these parameters to mortality. In our cohort, male sex, hypoxia (SpO2 <94% ) on admission, need for respiratory support, inotropes, intensive care, length of hospital stay <10 days was significantly associated with mortality on univariate analysis. Male gender has been associated with a higher risk of severe disease and mortality because of higher ACE-2 receptor expression . On regression analysis ,SpO2 <94% on admission and length of hospital stay of <10 days were predictors of mortality and not the presence of co-morbidities. Similar experience from adult studies has shown mortality within 1 to 2 weeks of ICU admission . To our knowledge, no pediatric study mentioning predictors of mortality has been conducted to date.
As a retrospective study, certain important parameters like onset of symptoms from day of contact, source of infection, and exact duration of COVID19 RT-PCR positivity in all children could not be assessed.