COVID-19 in the Paediatric Population

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Original Editor - User:Justin Bryan
Top Contributors - Justin Bryan and Lucinda hampton

Introduction

As the SARS-CoV-2 virus (COVID-19) has spread across the globe it has presented unique challenges for every population it has impacted.  While the impacts, symptom, and long term implications have been variable, one thing is clear, the virus will continue to effect many aspect of healthcare for some time.  Given this, it is important for providers to recognize the unique ways that COVID-19 impacts the populations they work with.  The following page will focus on the impacts of COVID-19 on the paediatric population, exploring some of the unique aspects that the virus presents in this diverse group of patients.

Characteristics and Clinical Presentation

Generally speaking, COVID-19 has presented trends suggesting that it is less severe in the paediatric and adolescent populations (<19 years of age) when compared to adult populations.  However, as new variants develop and spread through both developed and undeveloped countries, reports of complications such as multi-system inflammatory syndrome (MIS-C) and others have been reported.  Additionally, the impacts of prior and current public response, restrictions, and fear presented by the virus itself is only now being recognized as aspects of routine care such as vaccination and annual check-ups were and still are being disrupted.

Data and Trends from the Early Years of the Pandemic

While much focus was placed on the adult and older adult populations during the early days of the pandemic, a multitude of studies using data collected during this period now offer intriguing insights as to how the burgeoning virus impacted paediatric patients as well.

Data sets from 2020-2021 largely showed trends suggestive of lower illness severity and mortality among paediatric patients, with these cases accounting for between 1% and 10% of total cases.  With this, the greatest distribution of infections in children tended to center around school-aged individuals. Worldwide for this time period, data from China, Korea, Spain, Italy, and the United States collectively supported this consensus for an age group that included individuals <19 years of age.

Presentation of COVID-19 in Children and Adolescents

In the younger population, signs and symptoms of COVID-19, based on data from the early pandemic, tended to be more variable compared with infected adults. In general, the most common symptoms were fever and a cough, however, other complaints frequently included nausea/vomiting, diarrhea, nasal congestion, and shortness of breath. Asymptomatic presentations also tended to occur more often with this population compared to adults. Additionally, development of severe cases was also lower among children, with these cases generally felling in the age groups of <1 year and 10-14 years of age.  It is suggested that factors including viral load and comorbidities such as asthma, immune-suppression (i.e. cancer treatment), and congenital heart disease were predictive of increased risk of sever illness or hospitalization.

Given the increased virulence of SARS-CoV-2, the question has been raised as to why children and adolescents do not represent a higher percentage of cases, given that their immune systems are relatively less developed than adults. Several explanations have been suggested for this trend:

1. ACE2 receptors and protease TMPRSS2 are two components of a specific cell signaling process in the body that the COVID-19 virus exploits. The fact that this signaling pathways is less developed in children and adolescents may inherently reduce the virus' ability to function as optimally as it does in adults
2. Due to the active development of the immune system at younger ages, the innate immune system is naturally more active and thus provides greater protection
3. Given the strong correlation between comorbidities and the impact of the virus on the body, the presence of fewer comorbidities among children would naturally reduce their risk for infection and severe illness.
   

Diagnostic Procedures

The American Academy of Pediatrics (AAP) has developed suggested guidelines for when children should should be tested for COVID-19. Testing is generally similar to that of adults with tests like polymerase chain reaction (PCR) and antigen testing commonly used to detect a COVID-19 infection. A healthcare provider should be consulted prior to administering a specific test.

Suggested instances where children should be tested include:

• Immediately upon presentation of COVID-19 sign and symptoms (i.e. fever, cough, shortness of breath)
• At least 5 days after contact with a known or suspected positive case of COVID-19
• When mandated by public health guidelines

A prior confirmed COVID-19 infection in an individual should also be taken into account if that infection occurred with 30-90 days of a current instance for considering tests as this prior infection may impact the accuracy of the test.

• Asymptomatic children who have been exposed to a known or suspected COVID-19 positive case AND have previously tested positive within 30 day are NOT recommended to to be tested again
• Children who were COVID-19 positive within 30 days and present NEW symptoms should received an antigen tests to detect a new infection. Negative antigen tests should be repeated 48 hrs later to confirm results
• Children exposed to a know or suspected COVID-19 positive case AND have tested positive themselves between 30 and 90 days prior to the exposure may receive antigen testing at least 5 days after exposure to check for new infection
  

Management / Interventions

A full explanation of the management and treatment of COVID-19 in children and adolescents is beyond the scope of this resource. However, a brief overview of current approaches is provided as follows:

Published in March of 2022, the Australian National COVID‐19 Clinical Evidence Taskforce examined a multitude of evidence and released recommendations regarding treatment and management of COVID-19 in children.

Treatment	Level of Evidence	Reccomendation
Corticosteroid Medications	Conditional Recommendation / low certainty	Corticosteroids like dexamethasone may be considered for use in the treatment of acute COVID-19 in children (<19 y/o) who require oxygen support, including mechanical ventilation Corticosteroids should not be considered for the treatment of acute COVID-19 in children (<19 y/o) who do not require oxygen support
Tocilizumab (Biologic medication)	Conditional Recommendation / low certainty	Tocilizumab may be considered for use in the treatment of acute COVID-19 in children (<19 y/o) who require oxygen support, including mechanical ventilation Tocilizumab should be additionally considered especially in the above situation where signs of systemic inflammation are also present
Remdesivir	Conditional Recommendation / low certainty	Remdesivir is NOT recommended for acute treatment of COVID-19 in children (<19 y/o)
Azithromycin Colchicine Convalescent plasma Hydroxychloroquine Hydroxychloroquine plus Azithromycin Interferon‐β‐1a Lopinavir‐ritonavir or interferon‐β‐1a plus lopinavir‐ritonavir	Strong Recommendation / High certainty	These treatments are NOT recommended for in children (<19 y/o) . Currently there is no evidence of the effectiveness of these treatments for acute COVID-19 in adults; this combined with a lack of evidence suggesting anything but a similar outcome for children informs this recommendation.

Differential Diagnosis

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Resources

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