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What are the clinical manifestations of children and adolescents hospitalized with coronavirus disease 2019 (COVID-19)?
In this case series of 50 children and adolescents hospitalized with COVID-19 infection, respiratory symptoms, while common, were not always present. Children hospitalized with COVID-19 commonly had comorbidities, infants had less severe disease, those with obesity were likely to receive mechanical ventilation, and elevated markers of inflammation at admission and during hospitalization were associated with severe disease.
Expanded testing, maintaining a high suspicion for severe acute respiratory syndrome coronavirus 2 infection given the variable presentation of COVID-19, risk stratification, and recognition of findings suggestive of immune dysregulation are crucial to effective COVID-19 management in children.
Descriptions of the coronavirus disease 2019 (COVID-19) experience in pediatrics will help inform clinical practices and infection prevention and control for pediatric facilities.
To describe the epidemiology, clinical, and laboratory features of patients with COVID-19 hospitalized at a children’s hospital and to compare these parameters between patients hospitalized with and without severe disease.
Design, Setting, and Participants
This retrospective review of electronic medical records from a tertiary care academically affiliated children’s hospital in New York City, New York, included hospitalized children and adolescents (≤21 years) who were tested based on suspicion for COVID-19 between March 1 to April 15, 2020, and had positive results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Detection of SARS-CoV-2 from a nasopharyngeal specimen using a reverse transcription–polymerase chain reaction assay.
Main Outcomes and Measures
Severe disease as defined by the requirement for mechanical ventilation.
Among 50 patients, 27 (54%) were boys and 25 (50%) were Hispanic. The median days from onset of symptoms to admission was 2 days (interquartile range, 1-5 days). Most patients (40 [80%]) had fever or respiratory symptoms (32 [64%]), but 3 patients (6%) with only gastrointestinal tract presentations were identified. Obesity (11 [22%]) was the most prevalent comorbidity. Respiratory support was required for 16 patients (32%), including 9 patients (18%) who required mechanical ventilation. One patient (2%) died. None of 14 infants and 1 of 8 immunocompromised patients had severe disease. Obesity was significantly associated with mechanical ventilation in children 2 years or older (6 of 9 [67%] vs 5 of 25 [20%]; P = .03). Lymphopenia was commonly observed at admission (36 [72%]) but did not differ significantly between those with and without severe disease. Those with severe disease had significantly higher C-reactive protein (median, 8.978 mg/dL [to convert to milligrams per liter, multiply by 10] vs 0.64 mg/dL) and procalcitonin levels (median, 0.31 ng/mL vs 0.17 ng/mL) at admission (P < .001), as well as elevated peak interleukin 6, ferritin, and D-dimer levels during hospitalization. Hydroxychloroquine was administered to 15 patients (30%) but could not be completed for 3. Prolonged test positivity (maximum of 27 days) was observed in 4 patients (8%).
Conclusions and Relevance
In this case series study of children and adolescents hospitalized with COVID-19, the disease had diverse manifestations. Infants and immunocompromised patients were not at increased risk of severe disease. Obesity was significantly associated with disease severity. Elevated inflammatory markers were seen in those with severe disease.
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Accepted for Publication: May 13, 2020.
Corresponding Author: Philip Zachariah, MD, MSc, Department of Pediatrics, Columbia University Irving Medical Center, 622 W 168th St, PH 4 West Room 473, New York, NY 10032 (email@example.com).
Published Online: June 3, 2020. doi:10.1001/jamapediatrics.2020.2430
Correction: This article was corrected on June 21, 2021, to add a supplement that lists of all the nonauthor collaborators.
Author Contributions: Dr Zachariah had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Zachariah, Johnson, Camille Halabi, Giordano, Schweickert, Babineau, Fenster, Orange, Saiman.
Acquisition, analysis, or interpretation of data: Zachariah, Johnson, Camille Halabi, Ahn, Sen, Fischer, Banker, Giordano, Manice, Diamond, Sewell, Carter, Fenster, Orange, McCann, Kernie, Saiman.
Drafting of the manuscript: Zachariah, Camille Halabi, Ahn, Saiman.
Critical revision of the manuscript for important intellectual content: Zachariah, Johnson, Camille Halabi, Sen, Fischer, Banker, Giordano, Manice, Diamond, Sewell, Schweickert, Babineau, Carter, Fenster, Orange, McCann, Kernie, Saiman.
Statistical analysis: Zachariah, Giordano.
Administrative, technical, or material support: Zachariah, Johnson, Camille Halabi, Fischer, Giordano, Manice, Diamond, Schweickert, Carter, Fenster, Orange, McCann.
Supervision: Zachariah, Babineau, Fenster, Orange, Kernie, Saiman.
Conflict of Interest Disclosures: Dr Orange reported personal fees from Takeda and ADMA Biologics and being a member of the scientific advisory board for Gigagen outside the submitted work. Dr Saiman reported grants from Merck, the CF Foundation, the National Institute of Allergy and Infectious Diseases, and the Bill and Melinda Gates Foundation and serving on the scientific advisory boards of Merck and AstraZeneca outside the submitted work. No other disclosures were reported.
Group Information: The Columbia Pediatric COVID-19 Management Group members are listed in Supplement 1.
Additional Contributions: We acknowledge the extraordinary work of physicians, nurses, respiratory therapists, and all staff at Columbia University Irving Medical Center, Weill Cornell Medicine, and NewYork-Presbyterian Hospital. Specifically, we would like to thank our nursing leadership: Tammy Compagnone, DNP, RN, Donna Johnson, MS, MBA, RN, Kenya Robinson, MSN, RN, Vepuka Kauari, MSN, RN, and Bernadette Khan, DNP, RN (NewYork-Presbyterian Hospital). We thank the families of the children included in this study. None of these individuals received compensation for their contributions.
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