Clinical Characteristics of Children with Coronavirus Disease 2019 in Hubei, China

Neurological Consequences of SARS-CoV-2 Infection and Concurrence of Treatment-Induced Neuropsychiatric Adverse Events in COVID-19 Patients: Navigating the Uncharted

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to the angiotensin-converting enzyme 2 (ACE2) receptor and invade the human cells to cause COVID-19-related pneumonia. Despite an emphasis on respiratory complications, the evidence of neurological manifestations of SARS-CoV-2 infection is rapidly growing, which is substantially contributing to morbidity and mortality. The neurological disorders associated with COVID-19 may have several pathophysiological underpinnings, which are yet to be explored. Hypothetically, SARS-CoV-2 may affect the central nervous system (CNS) either by direct mechanisms like neuronal retrograde dissemination and hematogenous dissemination, or via indirect pathways. CNS complications associated with COVID-19 include encephalitis, acute necrotizing encephalopathy, diffuse leukoencephalopathy, stroke (both ischemic and hemorrhagic), venous sinus thrombosis, meningitis, and neuroleptic malignant syndrome. These may result from different mechanisms, including direct virus infection of the CNS, virus-induced hyper-inflammatory states, and post-infection immune responses. On the other hand, the Guillain-Barre syndrome, hyposmia, hypogeusia, and myopathy are the outcomes of peripheral nervous system injury. Although the therapeutic potential of certain repurposed drugs has led to their off-label use against COVID-19, such as anti-retroviral drugs (remdesivir, favipiravir, and lopinavir-ritonavir combination), biologics (tocilizumab), antibiotics (azithromycin), antiparasitics (chloroquine and hydroxychloroquine), and corticosteroids (dexamethasone), unfortunately, the associated clinical neuropsychiatric adverse events remains a critical issue. Therefore, COVID-19 represents a major threat to the field of neuropsychiatry, as both the virus and the potential therapies may induce neurologic as well as psychiatric disorders. Notably, potential COVID-19 medications may also interact with the medications of pre-existing neuropsychiatric diseases, thereby further complicating the condition. From this perspective, this review will discuss the possible neurological manifestations and sequelae of SARS-CoV-2 infection with emphasis on the probable underlying neurotropic mechanisms. Additionally, we will highlight the concurrence of COVID-19 treatment-associated neuropsychiatric events and possible clinically relevant drug interactions, to provide a useful framework and help researchers, especially the neurologists in understanding the neurologic facets of the ongoing pandemic to control the morbidity and mortality.

Risk Factors for Severity in Children with Coronavirus Disease 2019: A Comprehensive Literature Review

The coronavirus disease 2019 (COVID-19) pandemic has affected hundreds of thousands of people. The authors performed a comprehensive literature review to identify the underlying mechanisms and risk factors for severe COVID-19 in children. Children have accounted for 1.7% to 2% of the diagnosed cases of COVID-19. They often have milder disease than adults, and child deaths have been rare. The documented risk factors for severe disease in children are young age and underlying comorbidities. It is unclear whether male gender and certain laboratory and imaging findings are also risk factors. Reports on other potential factors have not been published.

Administration of intravenous immunoglobulin in the treatment of COVID-19: A review of available evidence

Since December 31, 2019, unknown causes of pneumonia have been reported in Wuhan, China. This special pneumonia associated with a novel coronavirus was named 2019-nCoV by the World Health Organization (WHO) in January 2020. From the beginning of this infectious disease, clinicians and researchers have been endeavoring to discover an effective and suitable treatment for affected patients. To date, there is no definitive and specific treatments for coronavirus disease-19 (COVID-19) infection while drugs introduced are still in the clinical trial phase. Intravenous immune globulin (IVIG) is a biological product prepared from the serum and an optional treatment for patients with antibody deficiencies. In many countries, much attention has been paid to the use of IVIG in the treatment of patients with COVID-19. Due to the therapeutic importance of IVIG in virus infections, in the current study, we reviewed the possible effect of IVIG in viral infections and potential evidence of IVIG therapy in patients with COVID-19 virus.

Chest CT findings of coronavirus disease 2019 (COVID-19): A comprehensive meta-analysis of 9907 confirmed patients

OBJECTIVES

We performed a systematic review and meta-analysis of the prevalence of chest CT findings in patients with confirmed COVID-19 infection.

METHODS

Systematic review of the literature was performed using PubMed, Scopus, Embase, and Google Scholar to retrieve original studies on chest CT findings of patients with confirmed COVID-19, available up to 10 May 2020. Data on frequency and distribution of chest CT findings were extracted from eligible studies, pooled and meta-analyzed using random-effects model to calculate the prevalence of chest CT findings.

RESULTS

Overall, 103 studies (pooled population: 9907 confirmed COVID-19 patients) were meta-analyzed. The most common CT findings were ground-glass opacities (GGOs) (77.18%, 95%CI = 72.23-81.47), reticulations (46.24%, 95%CI = 38.51-54.14), and air bronchogram (41.61%, 95%CI = 32.78-51.01). Pleural thickening (33.35%, 95%CI = 21.89-47.18) and bronchial wall thickening (15.48%, 95%CI = 8.54-26.43) were major atypical and airway findings. Lesions were predominantly distributed bilaterally (75.72%, 95%CI = 70.79-80.06) and peripherally (65.64%, 95%CI = 58.21-72.36), while 8.20% (95%CI = 6.30-10.61) of patients had no abnormal findings and pre-existing lung diseases were present in 6.01% (95%CI = 4.37-8.23).

CONCLUSIONS

The most common CT findings in COVID-19 are GGOs with/without consolidation, reticulations, and air bronchogram, which often involve both lungs with peripheral distribution. However, COVID-19 might present with atypical manifestations or no abnormal findings in chest CT, which deserve clinicians' notice.

COVID-19 and congenital heart disease: an insight of pathophysiology and associated risks

OBJECTIVE

We aimed to examine the literature to determine if both paediatric and adult patients diagnosed with congenital heart disease (CHD) are at a higher risk of poor outcomes if they have the coronavirus disease 2019 (COVID-19), compared to those without CHD.

METHODS

A systematic review was executed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. To identify articles related to COVID-19 and CHD, an extensive literature search was performed on EMBASE, Medline, Scopus, and Global Health databases using keywords and MeSH terms.

RESULTS

A total of 12 articles met the inclusion criteria and were included for analysis in this systematic review. Two themes were identified for data extraction: evidence supporting higher risks in CHD patients and evidence against higher risks in CHD patients. After combining the data, there were 99 patients with CHDs out of which 12 required admissions to ICU.

CONCLUSION

This systematic review suggests that CHD may increase the risk of poor outcomes for those with COVID-19, but also highlights the necessity for more research with larger sample sizes in order to make a more justified conclusion, as the majority of papers that were analysed were case series and case reports. Future research should aim to quantify the risks if possible whilst accounting for various confounding factors such as age and treatment history.

Clinical characteristics of 182 pediatric COVID-19 patients with different severities and allergic status

Background

The pandemic of coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection has made widespread impact recently. We aim to investigate the clinical characteristics of COVID‐19 children with different severities and allergic status.

Methods

Data extracted from the electronic medical records, including demographics, clinical manifestations, comorbidities, laboratory and immunological results, and radiological images of 182 hospitalized COVID‐19 children, were summarized and analyzed.

Results

The median age was 6 years, ranging from 3 days to 15 years, and there were more boys (male‐female ratio about 2:1) within the studied 182 patients. Most of the children were infected by family members. Fever (43.4%) and dry cough (44.5%) were common symptoms, and gastrointestinal manifestations accounted for 11.0%, including diarrhea, abdominal discomfort, and vomiting. 71.4% had abnormal chest computed tomography (CT) scan images, and typical signs of pneumonia were ground‐glass opacity and local patchy shadowing on admission. Laboratory results were mostly within normal ranges, and only a small ratio of lymphopenia (3.9%) and eosinopenia (29.5%) were observed. The majority (97.8%) of infected children were not severe, and 24 (13.2%) of them had asymptomatic infections. Compared to children without pneumonia (manifested as asymptomatic and acute upper respiratory infection), children with pneumonia were associated with higher percentages of the comorbidity history, symptoms of fever and cough, and increased levels of serum procalcitonin, alkaline phosphatase, and serum interleukins (IL)‐2, IL‐4, IL‐6, IL‐10, and TNF‐α. There were no differences in treatments, duration of hospitalization, time from first positive to first negative nucleic acid testing, and outcomes between children with mild pneumonia and without pneumonia. All the hospitalized COVID‐19 children had recovered except one death due to intussusception and sepsis. In 43 allergic children with COVID‐19, allergic rhinitis (83.7%) was the major disease, followed by drug allergy, atopic dermatitis, food allergy, and asthma. Demographics and clinical features were not significantly different between allergic and nonallergic groups. Allergic patients showed less increase in acute phase reactants, procalcitonin, D‐dimer, and aspartate aminotransferase levels compared with all patients. Immunological profiles including circulating T, B, and NK lymphocyte subsets, total immunoglobulin and complement levels, and serum cytokines did not show any difference in allergic and pneumonia groups. Neither eosinophil counts nor serum total immunoglobulin E (IgE) levels showed a significant correlation with other immunological measures, such as other immunoglobulins, complements, lymphocyte subset numbers, and serum cytokine levels.

Conclusion

Pediatric COVID‐19 patients tended to have a mild clinical course. Patients with pneumonia had higher proportion of fever and cough and increased inflammatory biomarkers than those without pneumonia. There was no difference between allergic and nonallergic COVID‐19 children in disease incidence, clinical features, and laboratory and immunological findings. Allergy was not a risk factor for developing and severity of SARS‐CoV‐2 infection and hardly influenced the disease course of COVID‐19 in children.

Epidemiological profile of children and adolescents with COVID-19: a scoping review

OBJECTIVE

to map the epidemiological profile of children and adolescents with COVID-19 in the world literature.

METHODS

a scoping review systematized by the Joanna Briggs Institute protocol in the PubMed/MEDLINE, CINAHL, Web of Science, Scopus, Science direct and Google Scholar databases. Articles with children and/or adolescents with laboratory diagnosis of COVID-19 were used.

RESULTS

thirty-two articles were included in the review. Most children and adolescents were male, with contamination by family transmission. The most frequent clinical manifestations were fever, cough and diarrhea. Ten studies cited pre-existing condition/disease, and hospital length ranged from one to twenty days. Three deaths were reported and no study presented race/color, education and socioeconomic conditions.

CONCLUSION

it was possible to screen the epidemiological profile with information about age group, sex, probable contamination of the disease, clinical manifestations, presence of pre-existing disease/condition, hospitalization and deaths among children and adolescents with COVID-19.

Epidemiology of COVID-19 in Northern Ireland, 26 February 2020-26 April 2020

This paper describes the epidemiology of coronavirus disease 2019 (COVID-19) in Northern Ireland (NI) between 26 February 2020 and 26 April 2020, and analyses enhanced surveillance and contact tracing data collected between 26 February 2020 and 13 March 2020 to estimate secondary attack rates (SAR) and relative risk of infection among different categories of contacts of individuals with laboratory confirmed severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. Our results show that during the study period COVID-19 cumulative incidence and mortality was lower in NI than the rest of the UK. Incidence and mortality were also lower than in the Republic of Ireland (ROI), although these observed differences are difficult to interpret given considerable differences in testing and surveillance between the two nations. SAR among household contacts was 15.9% (95% CI 6.6%–30.1%), over 6 times higher than the SAR among ‘high-risk’ contacts at 2.5% (95% CI 0.9%–5.4%). The results from logistic regression analysis of testing data on contacts of laboratory-confirmed cases show that household contacts had 11.0 times higher odds (aOR: 11.0, 95% CI 1.7–70.03, P-value: 0.011) of testing positive for SARS-CoV-2 compared to other categories of contacts. These results demonstrate the importance of the household as a locus of SARS-CoV-2 transmission, and the urgency of identifying effective interventions to reduce household transmission.

Reopening Schools and the Dynamics of SARS-CoV-2 Infections in Israel: A Nationwide Study

BACKGROUND

The benefits of school reopening must be weighed against the morbidity and mortality risks and the impact of enhancing spread of COVID-19. We investigated the effects of school reopening and easing of social distancing restrictions on the dynamics of SARS-CoV-2 infections in Israel, between March-July 2020.

METHODS

We examined the nationwide agewise weekly incidence, prevalence, SARS-CoV-2 PCR tests, their positivity, COVID-19 hospitalizations and associated mortality. Temporal differences in these parameters following school reopening, school ending, and following easing of restrictions such as permission of large scale gatherings, were examined.

RESULTS

The incidence of SARS-CoV-2 infections gradually increased following school reopening in all age groups, with a significantly higher increase in adults compared to children. Higher relative ratios (RRs) of sample positivity rates 21-27 days following school reopening relative to positivity rates prior to openings were found for the age groups 40-59 (RR: 4.72, 95% CI: 3.26 - 6.83) and 20-39 years (RR: 3.37 [2.51 - 4.53]), but not for children aged 0-9 (RR: 1.46 [0.85 - 2.51]) and 10-19 years (RR: 0.93 [0.65 - 1.34]).No increase was observed in COVID-19 associated hospitalizations and deaths following school reopening. In contrast, permission of large-scale gatherings was accompanied by increases in incidence and positivity rates of samples for all age groups, and increased hospitalizations and mortality.

CONCLUSIONS

This analysis does not support a major role of school reopening in the resurgence of the COVID-19 curve in Israel. Easing restrictions on large scale gatherings was the major influence on this resurgence.

COVID-19 infection in children: A systematic review and meta-analysis of clinical features and laboratory findings

OBJECTIVE

We aimed to provide a meta-analysis of previously published papers on the COVID-19-related clinical features and laboratory findings in children.

METHOD

This meta-analysis was conducted by using Medline/PubMed, Scopus, Web of Sciences and Google Scholar. Finally, 32 articles were selected for full-text assessment.

RESULTS

The most frequent symptoms were fever, cough, vomiting, diarrhea, sore throat, and dyspnea. Regarding the combined results of the meta-analysis, fever (46%, 95% CI 40-53%), cough (37%, 95% CI 29-46%), diarrhea (19%, 95% CI 9-28%), and pharyngalgia (13%, 95% CI 5-20%) were the most widely reported symptom. Besides, positive RT-PCR test results (43%, 95% CI 33-53%), low oxygen saturation (38%, 95% CI 25-51%), and elevated D-dimer levels (36%, 95% CI 16-56%) were the most common laboratory findings.

CONCLUSION

This review found that clinical presentations were milder, the prognosis was better, and the mortality rate was lower in children with COVID-19 compared with adult patients; however, children are potential carriers, like adults, and can transmit the infection among the population. Therefore, early identification and intervention in pediatric patients with COVID-19 are essential in order to control the pandemic. Moreover, gastrointestinal symptoms were more common symptoms among children.

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

Background

The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.

Objective

The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.

Data Sources

We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.

Study Eligibility Criteria

We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.

Participants

The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).

Methods

The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.

Results

We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.

Conclusions

Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.

Pediatric lung imaging features of COVID-19: A systematic review and meta-analysis

RATIONALE

Pediatric COVID-19 studies have been mostly restricted to case reports and small case series, which have prevented the identification of specific pediatric lung disease patterns in COVID-19. The overarching goal of this systematic review and meta-analysis is to provide the first comprehensive summary of the findings of published studies thus far describing COVID-19 lung imaging data in the pediatric population.

METHODS

A systematic literature search of PubMed was performed to identify studies assessing lung-imaging features of COVID-19 pediatric patients (0-18 years). A single-arm meta-analysis was conducted to obtain the pooled prevalence and 95% confidence interval (95% CI).

RESULTS

A total of 29 articles (n = 1026 children) based on chest computerized tomography (CT) images were included. The main results of this comprehensive analysis are as follows: (1) Over a third of pediatric patients with COVID-19 (35.7%, 95% CI: 27.5%-44%) had normal chest CT scans and only 27.7% (95% CI: 19.9%-35.6%) had bilateral lesions. (2) The most typical pediatric chest CT findings of COVID-19 were ground-glass opacities (GGO) (37.2%, 95% CI: 29.3%-45%) and the presence of consolidations or pneumonic infiltrates (22.3%, 95% CI: 17.8%-26.9%). (3) The lung imaging findings in children with COVID-19 were overall less frequent and less severe than in adult patients. (4) Typical lung imaging features of viral respiratory infections in the pediatric population such as increased perihilar markings and hyperinflation were not reported in children with COVID-19.

CONCLUSION

Chest CT manifestations in children with COVID-19 could potentially be used for early identification and prompt intervention in the pediatric population.

COVID-19 pneumonia in an infant with a hemodynamically significant ventricular septal defect

Reports thus far suggest a mild course for acute COVID-19 infection in children; however, its effects in vulnerable paediatric populations, including children with haemodynamically significant congenital heart disease, have rarely been reported. We therefore report on a 4-month-old Hispanic male with a moderate sized conoventricular ventricular septal defect and pulmonary overcirculation who presented with COVID-19-associated pneumonia.

COVID-19 and Comorbidities: Is Inflammation the Underlying Condition in Children? A Narrative Review

This paper examines the potential link between COVID-19 and the presence of comorbidities and assesses the role of inflammation in this correlation. In COVID-19 patients, the most frequently associated diseases share a pathogenic inflammatory basis and apparently act as a risk factor in the onset of a more severe form of the disease, particularly in adulthood. However, in children, the understanding of the underlying pathogenic mechanisms is often complicated by the milder symptoms presented. A series of theories have, therefore, been put forward with a view of providing a better understanding of the role played by inflammation in this dramatic setting. All evidence available to date on this topic is discussed in this review.

Transmission of SARS-CoV-2 through breast milk and breastfeeding: a living systematic review

The pandemic of coronavirus disease 2019 (COVID-19) is caused by infection with a novel coronavirus strain, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). At present, there is limited information on potential transmission of the infection from mother to child, particularly through breast milk and breastfeeding. Here, we provide a living systematic review to capture information that might necessitate changes in the guidance on breast milk and breastfeeding given the uncertainty in this area. Our search retrieved 19,414 total records; 605 were considered for full-text eligibility and no ongoing trials were identified. Our review includes 340 records, 37 with breast milk samples and 303 without. The 37 articles with analyzed breast milk samples reported on 77 mothers who were breastfeeding their children; among them, 19 of 77 children were confirmed COVID-19 cases based on RT-PCR assays, including 14 neonates and five older infants. Nine of the 68 analyzed breast milk samples from mothers with COVID-19 were positive for SARS-CoV-2 RNA; of the exposed infants, four were positive and two were negative for COVID-19. Currently, there is no evidence of SARS-CoV-2 transmission through breast milk. Studies are needed with longer follow-up periods that collect data on infant feeding practices and on viral presence in breast milk.

Neumonía por COVID-19 en niños: De su etiología a su manejo

El COVID-19 es menos serio en niños que en adultos. Sin embargo, las afecciones respiratorias dominan el cuadro clínico de pacientes hospitalizados por COVID-19, aun en niños. En algunas series de casos, el deterioro del estado clínico, donde la disnea, la cianosis y el inicio del síndrome de dificultad respiratoria aguda (SDRA) emergieron ∼8–10 días después del inicio de la infección por SARS-CoV-2, pudo progresar rápidamente hasta la falla multiorgánica y la muerte. Esta revisión tiene como objetivo evaluar las características de la neumonía por COVID-19 en poblaciones pediátricas, comenzando con su etiología y sus mecanismos patológicos, para cerrar con su manejo clínico.

Patterns of Presentation of SARS-CoV-2 Infection in Children. Experience at the Italian Epicentre of the Pandemic

Background: COVID-19, a disease caused by the new coronavirus SARS-CoV-2, spread worldwide, and Bergamo was one of the most affected areas in Europe. Following the first outbreak, more than half of the population of the Bergamo province had been infected. We aimed to describe the patients admitted to our unit shortly after the first outbreak. Methods: we retrospectively reviewed the notes of all pediatric patients diagnosed with COVID-19. We enrolled patients with positive swabs or serology and classified them based on the pattern and the timing of presentation after the first outbreak. This setting was considered a reliable reflection of the consequences of unmitigated SARS-CoV-2 circulation. Results: We diagnosed 35 patients over a 3-month period and we identified six patterns presenting in two temporal phases: Early phase, Group 1 (median of 20 days from epidemic start, IQR: 15-27): neonatal sepsis (n.7), pneumonia (n.5), flu-like symptoms (n.2). Late phase, Group 2 (59:51-66 days, p < 0.001): MIS-C (n.18), neurological manifestations (n.3). Group 1 differed from Group 2 for younger age (1 vs. 8 years, p = 0.02), lower C-reactive protein (0.9 vs. 16.6 mg/dl, p = 0.008), procalcitonin (0.16 vs. 7.9 ng/ml, p = 0.008) and neutrophil count (3,765 vs. 6,780/μl, p = 0.006), higher rate of positive swabs (14/14 vs. 9/21, p < 0.001), higher lymphocyte count (3,000 vs. 930/μl, p = 0.006) and platelet count (323,000 vs. 210,000/μl, p = 0.009). Conclusions: Following an outbreak of unmitigated SARS-CoV-2 diffusion, infected children may present with clinical patterns suggesting two temporal clusters, the first characterized by markers of direct viral injury, the second suggesting an immune-mediated disease.

Clinical features of patients undergoing hemodialysis with COVID-19

Hemodialysis patients are susceptible to coronavirus disease 2019 (COVID-19). The aim of this study was to describe the epidemiological, clinical characteristics, and mortality-related risk factors for those who undergoing hemodialysis with COVID-19. We conducted a retrospective study. A total of 49 hemodialysis patients with COVID-19 (Group 1) and 74 uninfected patients (Group 2) were included. For patients in Group 1, we found the median age was 62 years (36-89 years), 59.3% were male, and the median dialysis vintage was 26 months. Twenty-eight patients (57%) had three or more comorbidities and two patients (4%) died. The most common symptoms were fever (32.7%) and dry cough (46.9%), while nine patients (18.4%) were asymptomatic. Blood routine tests indicated lymphocytopenia, the proportion of lymphocyte subsets was generally reduced, and chest CT scans showed ground-glass opacity (45.8%) and patchy shadowing (35.4%). However, these findings were not specific to hemodialysis patients with COVID-19, and similar manifestations could be found in patients without SARS-CoV-2 infection. In conclusion, for hemodialysis patients with COVID-19, lymphocytopenia and ground-glass opacities or patchy opacities were common but not specific to them, early active treatment and interventions against nosocomial infection can significantly reduce the mortality and the risk of SARS-CoV-2 infection.

Developing trustworthy recommendations as part of an urgent response (1-2 weeks): a GRADE concept paper

OBJECTIVES

The aim of this study is to propose an approach for developing trustworthy recommendations as part of urgent responses (1-2 week) in the clinical, public health, and health systems fields.

STUDY DESIGN AND SETTING

We conducted a review of the literature, outlined a draft approach, refined the concept through iterative discussions, a workshop by the Grading of Recommendations Assessment, Development and Evaluation Rapid Guidelines project group, and obtained feedback from the larger Grading of Recommendations Assessment, Development and Evaluation working group.

RESULTS

A request for developing recommendations within 2 week is the usual trigger for an urgent response. Although the approach builds on the general principles of trustworthy guideline development, we highlight the following steps: (1) assess the level of urgency; (2) assess feasibility; (3) set up the organizational logistics; (4) specify the question(s); (5) collect the information needed; (6) assess the adequacy of identified information; (7) develop the recommendations using one of the 4 potential approaches: adopt existing recommendations, adapt existing recommendations, develop new recommendations using existing adequate systematic review, or develop new recommendations using expert panel input; and (8) consider an updating plan.

CONCLUSION

An urgent response for developing recommendations requires building a cohesive, skilled, and highly motivated multidisciplinary team with the necessary clinical, scientific, and methodological expertise; adapting to shifting needs; complying with the principles of transparency; and properly managing conflicts of interest.

Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review

OBJECTIVES

Coronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients.

METHODS

We performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection.

RESULTS

From 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5-59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5-11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6-13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors.

CONCLUSIONS

This systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay.

COVID-19 in Children: A Narrative Review

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic is caused by the third known zoonotic coronavirus. It is a disease that does not spare any age group. The scientific community has been inundated with information since January. This review aims to summarise pertinent information related to COVID-19 in children.

METHODS

A literature search was conducted in 2020 on the PubMed, MEDLINE, and Embase databases, with the keyword "COVID 19" and "children". A bibliographic search of articles included was also undertaken. The abstracts were scanned to assess their appropriateness to be included in this narrative review. This was updated on the 11th April, 2020.

RESULTS

The aetiology, transmission, incubation, pathophysiology, clinical features and complications, and management are discussed.

CONCLUSION

Our understanding of COVID-19 is evolving as more reports are published. The growth of SARS-CoV2 is limited in children and they are often asymptomatic. The disease course is also milder. Continued research to understand its effect on children is important to help us manage the disease in these vulnerable populations in a timely fashion.

Respiratory Therapeutic Strategies in Children and Adolescents with COVID-19: A Critical Review

Evidence on the treatment strategies for the child population with critical conditions due to COVID-19 is scarce and lacks consensus. Thus, this study aimed to critically review non-pharmacological respiratory strategies for this population. Original studies were searched in six databases considering predefined inclusion criteria. Other studies and recommendations were also included after a manual search. Oxygen therapy, invasive (IMV) and non-invasive (NIV) ventilation were the most frequently addressed interventions. In general, the original studies have cited these strategies, but detailed information on the parameters used was not provided. The recommendations provided more detailed data, mainly based on experiences with other acute respiratory syndromes in childhood. In the context of oxygen therapy, the nasal catheter was the most recommended strategy for hypoxemia, followed by the high-flow nasal cannula (HFNC). However, the risks of contamination due to the dispersion of aerosols in the case of the HFNC were pointed out. Lung protective IMV with the use of bacteriological or viral filters was recommended in most documents, and there was great variation in PEEP titration. Alveolar recruitment maneuvers were mentioned in a few recommendations. NIV was not consensual among studies, and when selected, several precautions must be taken to avoid contamination. Airway suctioning with a closed-circuit was recommended to reduce aerosol spread. Information on prone positioning and physiotherapy was even more scarce. In conclusion, oxygen therapy seems to be essential in the treatment of hypoxemia. If necessary, IMV should not be delayed, and protective strategies are encouraged for adequate pulmonary ventilation. Information about techniques that are adjuvant to ventilatory support is superficial and requires further investigation.

Private Tour Guide to Pediatric Coronavirus Disease of 2019 and Multisystem Inflammatory Syndrome in Children in 10 Minutes: What Thoracic Radiologists Need to Know

Filtering through the plethora of radiologic studies generated in response to the coronavirus disease of 2019 (COVID-19) pandemic can be time consuming and impractical for practicing thoracic radiologists with busy clinical schedules. To further complicate matters, several of the imaging findings in the pediatric patients differ from the adult population. This article is designed to highlight clinically useful information regarding the imaging manifestations of pediatric COVID-19 pneumonia, including findings more unique to pediatric patients, and multisystem inflammatory syndrome in children.

Risk profiles of severe illness in children with COVID-19: a meta-analysis of individual patients

BACKGROUND

We prepared a meta-analysis on case reports in children with COVID-19, aiming to identify potential risk factors for severe illness and to develop a prediction model for risk assessment.

METHODS

Literature retrieval, case report selection, and data extraction were independently completed by two authors. STATA software (version 14.1) and R programming environment (v4.0.2) were used for data handling.

RESULTS

This meta-analysis was conducted based on 52 case reports, including 203 children (96 boys) with COVID-19. By severity, 26 (12.94%), 160 (79.60%), and 15 (7.46%) children were diagnosed as asymptomatic, mild/moderate, and severe cases, respectively. After adjusting for age and sex, 11 factors were found to be significantly associated with the risk of severe illness relative to asymptomatic or mild/moderate illness, especially for dyspnea/tachypnea (odds ratio, 95% confidence interval, P: 6.61, 4.12-9.09, <0.001) and abnormal chest X-ray (3.33, 1.84-4.82, <0.001). A nomogram modeling age, comorbidity, cough, dyspnea or tachypnea, CRP, and LDH was developed, and prediction performance was good as reflected by the C-index.

CONCLUSIONS

Our findings provide systematic evidence for the contribution of comorbidity, cough, dyspnea or tachypnea, CRP, and LDH, both individually and jointly, to develop severe symptoms in children with asymptomatic or mild/moderate COVID-19.

IMPACT

We have identified potential risk factors for severe illness in children with COVID-19. We have developed a prediction model to facilitate risk assessment in children with COVID-19. We found the contribution of five risk factors to develop severe symptoms in children with asymptomatic or mild/moderate COVID-19.

Imaging characteristics of coronavirus disease 2019 (COVID-19) in pediatric cases: a systematic review and meta-analysis

BACKGROUND

The confirmed coronavirus disease 2019 (COVID-19) cases, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have exceeded 21 million (with more than 775,000 fatalities), and the number of children with COVID-19 is also increasing. This study aimed to summarize the chest imaging characteristics of pediatric COVID-19 cases and provide a reference for the diagnosis and control of pediatric COVID-19.

METHODS

The study protocol was registered in PROSPERO, number CRD42020177391. Studies related to pediatric COVID-19 imaging manifestations were accessed from PubMed, Web of Science, and the Cochrane library databases, without language limitations. The publication date was limited to April 1, 2020, and it was updated on May 1 and May 27, 2020. Data normalization was determined with the Freeman-Tukey double arcsine transformation. Summarized incidences with 95% confidence intervals of various imaging manifestations were assessed by random-effects models. Heterogeneity was assessed with meta-regression and subgroup analyses, robustness with sensitivity analyses; and publication biases with Egger's test.

RESULTS

Twenty-three with 517 cases were included in this study. The summarized incidence of chest computed tomography abnormalities in pediatric COVID-19 cases was 70%, which was lower than what has been seen in adults. The incidence of halo signs in pediatric COVID-19 cases was 26%, which is rarely seen in adult COVID-19 cases. The incidences of ground-glass opacities (GGOs), GGOs and consolidations, consolidations, reverse halo signs, crazy paving signs, pleural effusion, bronchopneumonia-like signs, air bronchograms, and increased lung markings were 40%, 25%, 10%, 2%, 4%, 1%, 15%, 12%, and 31%, respectively. Pericardial effusions were found in the computed tomography images of adult COVID-19 cases but were scarcely seen in the computed tomography images of pediatric COVID-19 cases. The incidences of bilateral lesions, unilateral lesions, and peripheral lesions were 35%, 22%, and 26%, respectively.

CONCLUSIONS

Chest computed tomography imaging of pediatric COVID-19 cases resulted in various abnormalities that were milder than those of adults. This study will hopefully provide a reference to help identify pediatric COVID-19 cases.

COVID-19: a review of current knowledge regarding exposure, quarantine, isolation and other preventive measures

Deeper understanding of the spread, morbidity, fatality, and development of immune response associated with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is necessary in order to establish an appropriate epidemiological and clinical response. Exposure control represents a key part of the combat against COVID-19, as the effectiveness of current therapeutic options remains partial. Since the preventive measures have not been sufficiently able to slow down this pandemic, in this article we explore some of the pertinent knowledge gaps, while overall looking to effective vaccination strategies as a way out. Early on, such strategies may need to rely on counting the convalescents as protected in order to speed up the immunization of the whole population.

Serum IgG levels in children 6 months after SARS-CoV-2 infection and comparison with adults

Since the outbreak of SARS-CoV-2 among the population has occurred quite recently, there is a lack of evidence on the long-term duration of antibody response, especially in children. It is therefore crucial to clarify this aspect, considering its implications in the development of successful surveillance strategies, therapies, and vaccinations. The aim of this study was to assess the antibody response in a children group after SARS-CoV-2 infection, and to compare it with that of their parents affected by SARS-CoV-2 infection. We enrolled 12 children and their parents, both groups being affected by COVID-19 in April 2020. In the children's group, we collected real-time RT-PCR cycle threshold (Ct) values and gene characterization of first nasal-throat swab at the time of diagnosis (T0); 30 days after the diagnosis (T30), we performed blood tests to detect anti-SARS-CoV-2 IgM and IgG. Finally, 180 days after the diagnosis (T180), we measured anti-SARS-CoV-2 IgG in both children and parents. In children, antibody levels declined significantly at 180 days (T180) after first measurement (T30). There were no significant differences in IgG level related to age, sex, and clinical manifestations. We found a significant correlation between IgG titers at T30 and Ct value of gene N. Children showed a lower level of antibodies against SARS-CoV-2 at T180 compared to their parents.Conclusion: Antibody responses in children waned 180 days after SARS-CoV-2 infection, and at the same time, their parents showed a different antibody response to the virus. These results highlight that serological tests should be used with caution in surveillance strategies among the general population. What is known: • Currently is not known how long antibody response will be maintained or if it protects from reinfection. • Recent reports in adults suggest that antibodies to SARS-CoV-2 declined several months after infection, but data are missing in pediatric age. What is new: • We showed that antibody responses to SARS-CoV-2 wane several months after infection also in children with quantitative differences in antibody levels between children and adults. • In this context, serological tests should be used with caution in surveillance strategies.

Decoding the silent walk of COVID-19: Halting its spread using old bullets

Severe acute respiratory syndrome (SARS) develops within 3-14 days when CoV2 invades epithelial, myeloid cells in the nasopharynx and pneumocytes in the respiratory tract through angiotensin converting enzyme (ACE2). Infection swiftly disseminates to gastrointestinal, cardiovascular, renal organs as well as immune system to deregulate their normal functioning through unique and distinct mechanisms. The health system and economy has been intensely thwarted by the rapid spread and exorbitant mortality caused by COVID-19 disease across the globe. The acute progression of the disease and high infection rate pose an enormous challenge for its therapeutic management and critical care. The viral structure, genome and proteome have been deciphered which yielded cues for targeting already available therapeutic entities. More than 200 compounds have been screened and till date approximately 69 therapeutic agents are undergoing clinical trials across the world. Among these, remedesivir (RMD), chloroquine (CQ), hydroxychloroquine (HCQ), noscapine (NOS) and heparin have demonstrated fairly promising results in preclinical and clinical studies. Recently, RMD has been approved by USFDA for the management of COVID 19. However, intense research is going on to screen and ace the 'magic bullets' for the management of SARS-CoV2 infection worldwide. The current review illustrates the plausible therapeutic targets in SARS-CoV2 important for inhibition of virus cycle. In addition, the role of RMD, CQ, HCQ, NOS and heparin in combating infection has been addressed. The importance of vitamin C and D supplements as adjunct therapies in the prevention of SARS-CoV2 virus infection have also been summarized.

The Impact of COVID-19 Pandemic in Children With Cancer: A Report From Saudi Arabia

In January 2020, the WHO declared the novel coronavirus (2019-nCoV) outbreak as a public health emergency of international concern. Due to the rapid spread of 2019-nCoV, all countries started preventive and precautionary measures to prevent COVID-19 infection spread. These measures limited the population mobility and services provided, which subsequently Impact of on children with cancer and cancer care delivery in the many health centers in Saudi Arabia. We did a cross-sectional study to assess the impact of this outbreak on children with cancer concerning all aspects of life including medical services provided, the specific precautions to prevent spread in cancer patients, mental, psychological effects, and its effect on the quality of life. We collected 204 responses during a survey that assessed the impact on the treatment of cancer children at a tertiary institution during the COVID-19 pandemic. The majority of patients were receiving ongoing chemotherapy for leukemia/lymphoma. The majority of these patients (60.5%) reported a delay in treatment received due to hospital cancellation of appointments due to the pandemic. Although the majority of patients in our cohort complained of delayed treatment, fortunately, none of the delays led to fatalities. In the context of global lockdowns and physical distancing to help flatten the COVID-19 curve, telemedicine has proved fundamental to keeping patients and their healthcare providers connected and safe. Children also faced multiple other difficulties such as psychosocial issues during the COVID-19 pandemic. Our long-term goals are to develop new programs that will enable children with cancer to emerge successfully during a pandemic.

A meta-analysis of accuracy and sensitivity of chest CT and RT-PCR in COVID-19 diagnosis

Nowadays there is an ongoing acute respiratory outbreak caused by the novel highly contagious coronavirus (COVID-19). The diagnostic protocol is based on quantitative reverse-transcription polymerase chain reaction (RT-PCR) and chests CT scan, with uncertain accuracy. This meta-analysis study determines the diagnostic value of an initial chest CT scan in patients with COVID-19 infection in comparison with RT-PCR. Three main databases; PubMed (MEDLINE), Scopus, and EMBASE were systematically searched for all published literature from January 1st, 2019, to the 21st May 2020 with the keywords "COVID19 virus", "2019 novel coronavirus", "Wuhan coronavirus", "2019-nCoV", "X-Ray Computed Tomography", "Polymerase Chain Reaction", "Reverse Transcriptase PCR", and "PCR Reverse Transcriptase". All relevant case-series, cross-sectional, and cohort studies were selected. Data extraction and analysis were performed using STATA v.14.0SE (College Station, TX, USA) and RevMan 5. Among 1022 articles, 60 studies were eligible for totalizing 5744 patients. The overall sensitivity, specificity, positive predictive value, and negative predictive value of chest CT scan compared to RT-PCR were 87% (95% CI 85-90%), 46% (95% CI 29-63%), 69% (95% CI 56-72%), and 89% (95% CI 82-96%), respectively. It is important to rely on the repeated RT-PCR three times to give 99% accuracy, especially in negative samples. Regarding the overall diagnostic sensitivity of 87% for chest CT, the RT-PCR testing is essential and should be repeated to escape misdiagnosis.

Characteristics and risk factors associated with critical illness in pediatric COVID-19

BACKGROUND

While much has been reported regarding the clinical course of COVID-19 in children, little is known regarding factors associated with organ dysfunction in pediatric COVID-19. We describe critical illness in pediatric patients with active COVID-19 and identify factors associated with PICU admission and organ dysfunction. This is a retrospective chart review of 77 pediatric patients age 1 day to 21 years admitted to two New York City pediatric hospitals within the Northwell Health system between February 1 and April 24, 2020 with PCR + SARS-CoV-2. Descriptive statistics were used to describe the hospital course and laboratory results and bivariate comparisons were performed on variables to determine differences.

RESULTS

Forty-seven patients (61%) were admitted to the general pediatric floor and thirty (39%) to the PICU. The majority (97%, n = 75) survived to discharge, 1.3% (n = 1) remain admitted, and 1.3% (n = 1) died. Common indications for PICU admission included hypoxia (50%), hemodynamic instability (20%), diabetic ketoacidosis (6.7%), mediastinal mass (6.7%), apnea (6.7%), acute chest syndrome in sickle cell disease (6.7%), and cardiac dysfunction (6.7%). Of PICU patients, 46.7% experienced any significant organ dysfunction (pSOFA >  = 2) during admission. Patients aged 12 years or greater were more likely to be admitted to a PICU compared to younger patients (p = 0.015). Presence of an underlying comorbidity was not associated with need for PICU admission (p = 0.227) or organ dysfunction (p = 0.87). Initial white blood cell count (WBC), platelet count, and ferritin were not associated with need for PICU admission. Initial C-reactive protein was associated with both need for PICU admission (p = 0.005) and presence of organ dysfunction (p = 0.001). Initial WBC and presenting thrombocytopenia were associated with organ dysfunction (p = 0.034 and p = 0.003, respectively).

CONCLUSIONS

Age over 12 years and initial CRP were associated with need for PICU admission in COVID-19. Organ dysfunction was associated with elevated admission CRP, elevated WBC, and thrombocytopenia. These factors may be useful in determining risk for critical illness and organ dysfunction in pediatric COVID-19.

EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW

Objective:

To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19.

Data sources:

Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded.

Data synthesis:

61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review.

Conclusions:

It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.

Evaluation of the Clinical Features of 81 Patients with COVID-19: An Unpredictable Disease in Children

Objective Data on the prognosis of clinical features of pediatric patients affected by the coronavirus disease 2019 (COVID-19) pandemic is insufficient. This study aimed to examine the clinical, laboratory, and radiology findings of pediatric patients diagnosed with COVID-19.

Methods A total of 81 pediatric patients with a confirmed diagnosis of COVID-19 who were admitted to the pediatric clinics of our tertiary care hospital in Istanbul between March 22 and May 1, 2020, were included in the study.

Results Of the patients, 40 (49.6%) were boys and 41 (50.6%) were girls. The mean age of the patients was 9.3 ± 5.5 years (range: 1 month–16 years). The most common symptoms were cough (28.4%) and fever (25.9%). A total of 26 patients (32.1%) had pharyngeal erythema. There was no significant difference between age groups in terms of symptoms, findings, clinical picture, history of contact, and clinical course (p > 0.001 for each). Abnormal findings were observed in seven (8.6%) patients on chest X-ray, and in four patients (4.9%) on thorax computed tomography. Only three of the patients were hospitalized and all of them discharged with healing.

Conclusion The present study is the most comprehensive study on children diagnosed with COVID-19 in our country, which showed that the COVID-19 picture was mild in pediatric patients, but the signs and symptoms in children were not specific to the disease. Our findings also showed that the rate of asymptomatic infection in children was high and that it was difficult to recognize COVID-19 in children.

COVID-19 Pneumonia in Children: From Etiology to Management

COVID-19 is less serious in children than in adults. However, respiratory management dominates the clinical picture of hospitalized COVID-19 even in children. In some case series, deterioration of the clinical picture wherein dyspnea, cyanosis, and the onset of acute respiratory distress syndrome (ARDS) emerged ~8-10 days after the onset of SARS-CoV-2 infection, which could rapidly progress to multiple organ failure and death. This review aimed to evaluate the characteristics of COVID-19 pneumonia in pediatric populations, beginning from its etiology and pathological mechanisms and closing with its clinical management.

Prevalence, clinical characteristics, and outcomes of pediatric COVID-19: A systematic review and meta-analysis

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COVID-19 pediatric data from major world-wide epicenters is severely lacking as compared to the adult population.

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Pediatric cases of COVID-19 tend to have a mild course and an overall favorable prognosis.

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Clinical, laboratory, and radiological features are largely inconsistent and solely not predictive of the disease diagnosis.

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This study may provide important insights into the characterization and management of COVID-19 in the pediatric population.

Introduction

The novel coronavirus pandemic is an ongoing challenge faced by the public and health care systems around the globe. Majority of information and evidence gathered so far regarding COVID-19 has been derived from data and studies in adult populations. Crucial information regarding the characterization, clinical symptomatology, sequelae, and overall outcomes in the pediatric population is lacking. As such, we aimed to conduct a comprehensive meta-analysis and systematic review to collect and analyze current evidence about COVID-19 in the pediatric population.

Method

A systematic search and review of scientific literatures was conducted following the PRISMA guidelines using PubMed, Embase, Scopus, Medline, and Google Scholar databases. All relevant studies until June 16, 2020 were included. Studies were reviewed for methodological quality, and random-effects model was used to conduct the primary meta-analysis. I² value and Egger’s test was used to estimate heterogeneity and publication bias respectively.

Results

We reviewed 20 eligible studies that included 1810 pediatric patient population (<21 yo) with PCR tested COVID-19 positivity. In pooled data, majority (25 % [CI 18–32], I² 59 %) of overall COVID-19 positive patients fell in the 6−10 yr age group. 13 % ([CI 11–14], I² 78 %) of the patients were asymptomatic, with headache (67 % [CI 60–74], I² 46 %), fever (55 % [CI 52–58], I² 61 %), and cough (45 % [CI 42–49], I² 79 %) accounting for the most prevalent physical signs seen in symptomatic patients. Leukopenia (12 % [CI 9–15], I²50 %) and lymphopenia (15 % [CI 13–19], I² 85 %) was common. Elevated Ferritin (26 % [CI 16–40], I² 73 %), Procal (25 % [CI 21–29 %], I² 83 %), and CRP (19 % [CI 16–22 %], I² 74 %) were other laboratory abnormalities commonly observed. Common radiological features were ground-glass opacities (36 % [CI 32–39 %], I² 92 %), normal finding (33 % [CI 30–36 %], I² 81 %), and consolidation. 29 % ([CI 26–33], I² 85 %) of the patient cases was non-severe, whereas only 5 % ([CI 1–8], I² 87 %) was severe. Mortality was observed in 0.3 % ([CI 0.1−0.4], I² 0%) of the overall cases.

Conclusion

COVID-19 is prevalent across all pediatric age-groups and presents with varying degree of symptomology. However, children have a milder course of the disease with extremely favorable prognosis. Laboratory and radiological features are inconsistent and require further investigations. Additional studies are needed on this topic to corroborate findings and establish evidence-based and consistent characterization of COVID-19 in the pediatric population.

Ten Epidemiological Parameters of COVID-19: Use of Rapid Literature Review to Inform Predictive Models During the Pandemic

Objective: To describe the methods used in a rapid review of the literature and to present the main epidemiological parameters that describe the transmission of SARS-Cov-2 and the illness caused by this virus, coronavirus disease 2019 (COVID-19). Methods: This is a methodological protocol that enabled a rapid review of COVID-19 epidemiological parameters. Findings: The protocol consisted of the following steps: definition of scope; eligibility criteria; information sources; search strategies; selection of studies; and data extraction. Four reviewers and three supervisors conducted this review in 40 days. Of the 1,266 studies found, 65 were included, mostly observational and descriptive in content, indicating relative homogeneity as to the quality of the evidence. The variation in the basic reproduction number, between 0.48 and 14.8; and the median of the hospitalization period, between 7.5 and 20.5 days stand out as key findings. Conclusion: We identified and synthesized 10 epidemiological parameters that may support predictive models and other rapid reviews to inform modeling of this and other future public health emergencies.

Evaluation of the novel coronavirus disease in Turkish children: Preliminary outcomes

BACKGROUND

The novel coronavirus disease (Covid-19) can progress with mild to moderate or self-limiting clinical findings in children. The aim of this study was to investigate the disease features of Covid-19 in Turkish children.

METHODS

Children diagnosed by the method of real-time reverse transcription-polymerase chain reaction for Covid-19 at the Dicle University Department of Pediatric, between April and June 2020, were evaluated. Hospital records were investigated retrospectively.

RESULTS

One hundred and five patients children with the mean age of 108.64 ± 65.61 months were enrolled in this study. The most common cause of transmission in pediatric patients was in contact with a family member diagnosed with COVID-19 (n = 91, 86.7%). The most common admission complaints were dry cough (n = 17, 16.2%), fever (n = 16, 15.2%), lassitude and fatigue (n = 14, 13.3%) respectively. More than 95% of all children with Covid-19 were asymptomatic, mild, or moderate cases. CRP was identified only independent factor associated with long duration of hospitalization.

CONCLUSION

The results of this study show the effect of Covid-19 on Turkish children. A clear understanding of the local epidemiology of corona virus infections and identification of risk factors are critical for the successful implementation of the prevention and control program.

An increasing public health burden arising from children infected with SARS-CoV2: A systematic review and meta-analysis

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is spreading all over the world and poses a great threat to humans. This study aimed to systematically review the current situation and public health burden associated with children infected with SARS-CoV2.

METHODS

We searched four electronic databases without language limitations. The pooled proportion or odds ratio (OR) and 95% CI confidence interval (CI) were calculated for each analysis to explore the prevalence of asymptomatic infection and coinfection, as well as to assess the sex of SARS-CoV-2-infected children.

RESULTS

We obtained data from 14 eligible studies with 410 patients for the meta-analysis. The pooled proportion of asymptomatic infection was 40.45% (95% CI, 24.04-56.85), while coinfection was 10.14% (95% CI, 3.97-16.30), of which Mycoplasma pneumonia (50%; 95% CI, 28.24-71.76) and influenza virus or parainfluenza virus (22.76%; 95% CI, 4.76-40.77) were the most common pathogens. Both male and female children were susceptible to SARS-CoV2 infection. And the pooled proportion of family clustering infection was 83.63% (95% CI, 77.54-89.72).

CONCLUSION

A high proportion of asymptomatic infections occurs in children infected with SARS-CoV2, who are also susceptible to coinfection regardless of sex. These data affirm the increasing public health burden arising from infected children regarding the causation of asymptomatic infection or misdiagnosis and as a significant contributor to virus spread. The public should pay more attention to children during epidemics and conduct multimethod detection to further effectively identify infected children and control the source of infection.

The Limited Sensitivity of Chest Computed Tomography Relative to Reverse Transcription Polymerase Chain Reaction for Severe Acute Respiratory Syndrome Coronavirus-2 Infection: A Systematic Review on COVID-19 Diagnostics

OBJECTIVES

Several studies suggest the sensitivity of chest computed tomography (CT) is far greater than that of reverse transcription polymerase chain reaction (RT-PCR) in diagnosing COVID-19 patients, and therefore, CT should be included as a primary diagnostic tool. This systematic review aims to stratify studies as high or low risk of bias to determine the true sensitivity of CT for severe acute respiratory syndrome coronavirus-2 infection according to the unbiased (low risk) studies, a topic of particular importance given the insufficient quantity of RT-PCR kits in many countries. We focus on sensitivity as that is the chief advantage perceived of CT.

MATERIALS AND METHODS

This systematic review involved searching the PubMed and Google Scholar databases for articles conducted and published between January 1 and April 15, 2020. The quality assessment tool QUADAS-2 was used to stratify studies according to their risk of bias, and exclusion criteria included not providing the information deemed relevant for such a stratification, such as not indicating if the patients were symptomatic or asymptomatic, or identifying the source of the specimen for the reference standard, RT-PCR (eg, nasal, oropharyngeal, etc). Sensitivity values were then extracted, and random effects meta-analyses were performed.

RESULTS

Of 641 search results, 37 studies (n = 9610 patients) were included in the analysis. The mean sensitivity of RT-PCR for COVID-19 reported by the biased studies was 70% (n = 5409/7 studies; 95% confidence interval [CI], 43-97; I = 99.1%), compared with 78% by unbiased studies (n = 534/4 studies; 95% CI, 69-87, I = 89.9%). For chest CT, the mean sensitivity reported by biased studies was 94% (n = 3371 patients/24 studies; 95% CI, 92-96; I = 93.1%), compared with 75% by unbiased studies (n = 957/10 studies; 95% CI, 67-83; I = 89.5%).

CONCLUSIONS

The difference between the sensitivities of CT and RT-PCR for severe acute respiratory syndrome coronavirus-2 infection is lower than previously thought, as after stratifying the studies, the true sensitivity for CT based on the unbiased studies is limited.

Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis

BACKGROUND

Bacterial co-pathogens are commonly identified in viral respiratory infections and are important causes of morbidity and mortality. The prevalence of bacterial infection in patients infected with SARS-CoV-2 is not well understood.

AIMS

To determine the prevalence of bacterial co-infection (at presentation) and secondary infection (after presentation) in patients with COVID-19.

SOURCES

We performed a systematic search of MEDLINE, OVID Epub and EMBASE databases for English language literature from 2019 to April 16, 2020. Studies were included if they (a) evaluated patients with confirmed COVID-19 and (b) reported the prevalence of acute bacterial infection.

CONTENT

Data were extracted by a single reviewer and cross-checked by a second reviewer. The main outcome was the proportion of COVID-19 patients with an acute bacterial infection. Any bacteria detected from non-respiratory-tract or non-bloodstream sources were excluded. Of 1308 studies screened, 24 were eligible and included in the rapid review representing 3338 patients with COVID-19 evaluated for acute bacterial infection. In the meta-analysis, bacterial co-infection (estimated on presentation) was identified in 3.5% of patients (95%CI 0.4-6.7%) and secondary bacterial infection in 14.3% of patients (95%CI 9.6-18.9%). The overall proportion of COVID-19 patients with bacterial infection was 6.9% (95%CI 4.3-9.5%). Bacterial infection was more common in critically ill patients (8.1%, 95%CI 2.3-13.8%). The majority of patients with COVID-19 received antibiotics (71.9%, 95%CI 56.1 to 87.7%).

IMPLICATIONS

Bacterial co-infection is relatively infrequent in hospitalized patients with COVID-19. The majority of these patients may not require empirical antibacterial treatment.

Hematological manifestations of SARS-CoV-2 in children

Infection from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), though mainly a respiratory disease, can impair many systems, including causing hematological complications. Lymphopenia and hypercoagulability have been reported in adults with coronavirus disease 2019 (COVID-19) and are considered markers of poor prognosis. This review summarizes the hematological findings in children with SARS-CoV-2 infection. The majority of infected children had a normal leukocyte count, while the most common white blood cell abnormality was leukopenia. Lymphopenia, which may be a marker of severe disease, was rarer in children than in adults, possibly due to their immature immune system or due to the less severe manifestation of COVID-19 in this age group. Age may have an impact, and in neonates and infants the most common abnormality was lymphocytosis. Abnormalities of red blood cells and platelets were uncommon. Anemia and hypercoagulability were reported mainly in children presenting the novel multisystem inflammatory syndrome (MIS) associated with SARS-CoV-2.

Pharmacotherapy of Acute COVID-19 Infection and Multisystem Inflammatory Syndrome in Children: Current State of Knowledge

Background: The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic is a health care emergency across the world. Although mitigation measures, such as social distancing and face masks, have attempted to slow the spread of the infection, cases continue to rise. Children who are otherwise healthy tend to develop a milder acute Coronavirus disease 2019 (COVID-19) infection and have lower mortality rates compared with adults. Methods: Guidelines and current primary and secondary literature on the treatment of COVID-19 and the multisystem inflammatory syndrome in children were searched and reviewed. There are 6 published pediatric series that included 252 children with acute COVID-19 infection and describe various treatments and outcomes. Results: Guidelines recommend treating pediatric patients similarly to adult patients. Currently, no prophylactic drug therapy has been shown to reduce the spread of infection. Treatment options for acute COVID-19 are limited to remdesivir and glucocorticoids for patients who require oxygen and/or mechanical ventilation. The efficacy of hydroxychloroquine, chloroquine, and azithromycin has not been proven and their safety has been a concern. Other therapies that are being explored include interleukin (IL)-1 and IL-6 inhibitors. In children, an atypical Kawasaki-like disease emerged after recent exposure to SARS-CoV-2 and has been named Multisystem Inflammatory Syndrome in Children (MIS-C). Nine case series, including 418 pediatric patients, described pharmacotherapies used and patient outcomes. These pharmacotherapies included intravenous immune globulin and glucocorticoids and in some patients, IL-1 and IL-6 inhibitors. Conclusion: Given the paucity of data in children, this article presents currently recommended pharmacotherapies for the treatment of acute COVID-19 infection in adult patients and whenever available, in pediatric patients. Pharmacotherapies used in the treatment of MIS-C in children are also reviewed.

Coronavirus global pandemic: An overview of current findings among pediatric patients

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic has been emerged as a cardinal public health problem. Children have their own specific clinical features; notably, they seem to be escaping the severe respiratory adverse effects. The international scientific community is rapidly carrying out studies, driving to the need to reassess knowledge of the disease and therapeutic strategies.

AIM

To assess the characteristics of COVID-19 infected children worldwide of all ages, from neonates to children and adolescents, and how they differ from their adult counterparts.

SEARCH STRATEGY

An electronic search in PubMed was conducted, using combinations of the following keywords: coronavirus, SARS-CoV-2, COVID-19, children. The search included all types of articles written in English between January 1, 2019 until August 15, 2020.

RESULTS

The search identified 266 relevant articles. Children were mainly within family clusters of cases and have relatively milder clinical presentation compared with adults; children were reported to have better outcomes with a significantly lower mortality rate. Cough and fever were the most common symptoms while pneumonia was the cardinal respiratory manifestation of infected children. Laboratory results and thoracic imaging give varying results.

CONCLUSIONS

Children were mainly family cluster cases and usually presented with a mild infection, although cases presented with the multisystem inflammatory syndrome are becoming more apparent. Studies determining why the manifestations of SARS-CoV-2 infection are so variable may help to gain a better understanding of the disease and accelerate the development of vaccines and therapies.

Prevalence of COVID-19 Diagnostic Output with Chest Computed Tomography: A Systematic Review and Meta-Analysis

BACKGROUND

The pooled prevalence of chest computed tomography (CT) abnormalities and other detailed analysis related to patients' biodata like gender and different age groups have not been previously described for patients with coronavirus disease 2019 (COVID-19), thus necessitating this study. Objectives: To perform a meta-analysis to evaluate the diagnostic performance of chest CT, common CT morphological abnormalities, disease prevalence, biodata information, and gender prevalence of patients.

METHODS

Studies were identified by searching PubMed and Science Direct libraries from 1 January 2020 to 30 April 2020. Pooled CT positive rate of COVID-19 and RT-PCR, CT-imaging features, history of exposure, and biodata information were estimated using the quality effect (QE) model.

RESULTS

Out of 36 studies included, the sensitivity was 89% (95% CI: 80-96%) and 98% (95% CI: 90-100%) for chest CT and reverse transcription-polymerase chain reaction (RT-PCR), respectively. The pooled prevalence across lesion distribution were 72% (95% CI: 62-80%), 92% (95% CI: 84-97%) for lung lobe, 88% (95% CI: 81-93%) for patients with history of exposure, and 91% (95% CI: 85-96%) for patients with all categories of symptoms. Seventy-six percent (95% CI: 67-83%) had age distribution across four age groups, while the pooled prevalence was higher in the male with 54% (95% CI: 50-57%) and 46% (95% CI: 43-50%) in the female.

CONCLUSIONS

The sensitivity of RT-PCR was higher than chest CT, and disease prevalence appears relatively higher in the elderly and males than children and females, respectively.

COVID-19 in Pediatric Patients: A Focus on CHD Patients

Coronavirus disease 2019 (COVID-19) is a global pandemic caused by SARS-CoV-2 virus. As of the 30th of September 2020, around 34,000,000 cases have been reported globally. Pediatrics with underlying congenital heart disease represent a small yet a critical proportion of these patients. In general, the majority of infected children experience mild to moderate disease with significant interindividual variability in laboratory and radiographic findings. Nevertheless, in healthy children with COVID-19, cardiac involvement has been documented and is attributed to various causes. Myocarditis, arrhythmias, cardiogenic shock, and serious multisystem inflammatory syndrome in children are all encountered. Since COVID-19 is a recent novel disease and based on previous experience with respiratory infections, children with underlying congenital heart disease should be given special attention. To date, little data is available about COVID-19 presentation, complications, and appropriate treatment in this population. However, variable and inconsistent disease presentation and severity have been observed. This paper discusses COVID-19 course of illness in pediatric population with a special emphasis on the cardiac manifestations of the disease in healthy population and also on the disease course in congenital heart disease patients in particular.

SARS-CoV-2 Pandemic Impact on Pediatric Emergency Rooms: A Multicenter Study

From 9 March to 3 May 2020, lockdown was declared in Italy due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Our aim was to evaluate how the SARS-CoV-2 pandemic and related preventive strategies affected pediatric emergency rooms (ERs) during this period. We performed a retrospective cohort multicenter study, comparing the lockdown period to the corresponding period in 2019. We examined 15 Italian pediatric ERs in terms of visit rates, specific diagnoses (grouped as air communicable diseases and non-air communicable diseases), and triage categories. During the lockdown period, ER admissions decreased by 81% compared to 2019 (52,364 vs. 10,112). All ER specific diagnoses decreased in 2020 and this reduction was significantly higher for air communicable diseases (25,462 vs. 2934, p < 0.001). Considering the triage category, red codes remained similar (1% vs. 1%), yellow codes increased (11.2% vs. 22.3%), and green codes decreased (80.3% vs. 69.5%). We can speculate that social distancing and simple hygiene measures drastically reduced the spread of air communicable diseases. The increase in yellow codes may have been related to a delay in primary care and, consequently, in ER admissions.