Pediatric COVID-19
Corey Diamond
Near the beginning of the pandemic, there was an atmosphere of confidence that COVID-19 would not present a serious risk to children, much in the same way that chicken pox and the flu typically present a threat only to adults. However, the data trickling in since early January have revealed, unsurprisingly, a much grayer and more complex picture. Here’s what we knew at the time this article went to press.
CDC data
According to a CDC Morbidity and Mortality Weekly Report from April of this year, the total case prevalence of COVID-19 infections was approximately 1.7% in the pediatric population—age groups younger than 18 years. However, this figure is starkly contrasted with October 2020 real-time data from CDC’s demographic tracking system, which indicated a relative fivefold increase in the overall case prevalence—an increase to 9% from 1.7%.
Although there is a concern this figure may represent an artificial jump due to a relative increase in testing, a CDC weekly surveillance summary for week 42 of the pandemic indicated that all tests administered to children—from both public and commercial sources—has remained stable since late April.
Hospitalizations and death rates
In general, epidemiological studies have suggested that children are at a much lower risk of a severe COVID-19 disease course relative to adults, with a decreased risk of both hospitalization and death.
However, current data from CDC’s Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET) indicate that while age groups younger than 18 years have a reduced rate of hospitalization compared with adults—14 versus 244.5 hospitalizations per 100,000 cases—pediatric hospitalization rates continue to increase, with a staggering 15-fold relative increase compared with rates in early April. The death rates in this population appear to have remained relatively stable, however, at least since mid-April.
A retrospective analysis published in the Journal of the American Academy of Pediatrics examined pediatric COVID-19 cases over a 5-month period from various state health department databases. The study found that children comprised 0.07% of total COVID-19 cases and that 0.01% of child cases resulted in death, with comparably little fluctuation relative to hospitalization rates.
In addition, there also appears to be a large degree of similarity in how severe disease presents in both children and adults. Currently, according to COVID-NET, one-third of hospitalized pediatric patients with COVID-19 require admittance to an ICU, which is about the same rate as adult patients.
A cross-sectional study of 46 pediatric ICUs, published in JAMA in May 2020 by Shekedemian and colleagues, revealed that pediatric patients critically ill with COVID-19 have similar rates of certain complications as adults, including respiratory failure, myocarditis, shock, acute renal failure, and coagulopathy.
Cautious attitude
Reports continue to mount about a rare syndrome, known as multisystem inflammatory syndrome in children (MIS-C), that seems to occur only in children with COVID-19. The link appears to be strong, with 98% of pediatric patients with MIS-C testing positive for COVID-19. MIS-C is characterized as a clinically severe illness with evidence of inflammation in multiple organ systems that usually occurs 2 to 4 weeks after COVID-19 infection in pediatric patients.
CDC began tracking this syndrome around mid-May and has confirmed 1,097 cases as of October 15, with 20 total deaths.
Demographically, MIS-C seems to present in mainly Hispanic/Latinx and Black populations—comprising more than 75% of pediatric cases—and in children between the ages of 1 year and 14 years, with a maximum age of up to 20 years.
While the initial case statistics may be encouraging at first glance, the health care community should not assume a less cautious attitude toward the pediatric population. It’s important for practitioners to take the same precautions with children as they do with adults.
The American Academy of Pediatrics strongly endorses that all pediatric patients with COVID-19 have uninterrupted care with the use of appropriate personal protective equipment and aerosol mitigation strategies, similar to guidelines for adult patients.
If current trends continue, the pediatric population could require the same degree of scrutiny as the adult population, if not greater.