COVID-19 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review of critically unwell children and the association with underlying comorbidities

Abstract

Data show that children are less severely affected with SARS-Covid-19 than adults; however, there have been a small proportion of children who have been critically unwell. In this systematic review, we aimed to identify and describe which underlying comorbidities may be associated with severe SARS-CoV-2 disease and death. The study protocol was in keeping with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A total of 1726 articles were identified of which 28 studies fulfilled the inclusion criteria. The 28 studies included 5686 participants with confirmed SARS-CoV-2 infection ranging from mild to severe disease. We focused on the 108 patients who suffered from severe/critical illness requiring ventilation, which included 17 deaths. Of the 108 children who were ventilated, the medical history was available for 48 patients. Thirty-six of the 48 patients (75%) had documented comorbidities of which 11/48 (23%) had pre-existing cardiac disease. Of the 17 patients who died, the past medical history was reported in 12 cases. Of those, 8/12 (75%) had comorbidities. Conclusion: Whilst only a small number of children suffer from COVID-19 disease compared to adults, children with comorbidities, particularly pre-existing cardiac conditions, represent a large proportion of those that became critically unwell. What is Known:• Children are less severely affected by SARS-CoV-2 than adults.• There are reports of children becoming critically unwell with SARS-CoV-2 and requiring intensive care. What is New:• The majority of children who required ventilation for SARS-CoV-2 infection had underlying comorbidities.• The commonest category of comorbidity in these patients was underlying cardiac disease.

Factors Associated With Severe SARS-CoV-2 Infection

“…Several comorbidities have been associated with poor outcomes in adults, 35 including chronic respiratory and cardiac diseases, but these remain unclear for children. 7,18,28,36,37 Comorbidities were frequent in our cohort (29%, n=114), but these comorbidities were not independently associated with severe evolution, and accounted for only 22 severe cases of hospitalization on a national-scale. These observations may also help policy makers allow for standard school activities for these populations and help physicians to reassure families in this process.…”

Open Schools, Covid-19, and Child and Teacher Morbidity in Sweden

“…The results of an overview study published in May have been confirmed by several recent systematic reviews from several countries (11,12,17). The surveys show that a high proportion of children who became seriously ill and were on a ventilator had other underlying diseases (18), most commonly heart disease.…”

“…An overview of studies documenting a total of 108 patients under 18 with a serious progression of COVID-19 indicates that there may be a correlation between underlying diseases and COVID-19 in children, i.e. the severity of the disease (18). According to the survey and data from 48 patients under the age of 18 with severe disease progression of COVID-19, 75 percent had an underlying diseases.…”

Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infections

“…7 107-109 However, intriguingly, even children with serious medical conditions, who are on immunosuppressive or cancer treatment, are much less affected by COVID-19 than adults. [110][111][112][113]…”