Pediatric patients with COVID‐19 admitted to intensive care units in Brazil: a prospective multicenter study

Abstract

Objective: To describe the clinical characteristics of children and adolescents admitted to intensive care with confirmed COVID-19. Method: Prospective, multicenter, observational study, in 19 pediatric intensive care units. Patients aged 1 month to 19 years admitted consecutively (March–May, 2020) were included. Demographic, clinical-epidemiological features, treatment, and outcomes were collected. Subgroups were compared according to comorbidities, age < 1 year, and need for invasive mechanical ventilation. A multivariable logistic regression model was used for predictors of severity. Results: Seventy-nine patients were included (ten with multisystemic inflammatory syndrome). Median age 4 years; 54% male (multisystemic inflammatory syndrome, 80%); 41% had comorbidities (multisystemic inflammatory syndrome, 20%). Fever (76%), cough (51%), and tachypnea (50%) were common in both groups. Severe symptoms, gastrointestinal symptoms, and higher inflammatory markers were more frequent in multisystemic inflammatory syndrome. Interstitial lung infiltrates were common in both groups, but pleural effusion was more prevalent in the multisystemic inflammatory syndrome group (43% vs. 14%). Invasive mechanical ventilation was used in 18% (median 7.5 days); antibiotics, oseltamivir, and corticosteroids were used in 76%, 43%, and 23%, respectively, but not hydroxychloroquine. The median pediatric intensive care unit length-of-stay was five days; there were two deaths (3%) in the non- multisystemic inflammatory syndrome group. Patients with comorbidities were older, and comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5; 95% CI, 1.43–21.12; p = 0.01). Conclusions: In Brazilian pediatric intensive care units, COVID-19 had low mortality, age less than 1 year was not associated with a worse prognosis, and patients with multisystemic inflammatory syndrome had more severe symptoms, higher inflammatory biomarkers, and a greater predominance of males, but only comorbidities and chronic diseases were independent predictors of severity.

Emerging Evidence on Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection: a Systematic Review with Meta-analysis

“…Out of total 386 identified studies, data of 992 children from 17 studies was included in this systematic review, which included 144 patients from low-income and middle-income countries (LMICs), CDC data from the USA and published data from France, the UK, Italy, Spain, Chile and Japan [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] (PRISMA flow diagram Fig. 1).…”

“…Few may even need intensive care under a multidisciplinary team of paediatric infectious disease, cardiology, immunology, rheumatology, haematology and intensive care specialists. In our systematic review, 63% children [ 6 – 11 , 13 – 17 , 20 – 22 ] were admitted in PICU, 33% required invasive ventilation [ 6 – 9 , 12 – 15 , 19 , 20 , 22 ]. Patients with mild symptoms and/or well-appearing (normal vital signs and reassuring physical examination) can be managed in OPD.…”

“…In this review, 307 out of 658 (47%) patients presented with significantly elevated troponin or BNP [ 6 , 8 , 9 , 14 , 15 , 17 , 20 ], indicating myocardial cell injury, and 11 out of 747 (1.4%) patients developed arrhythmia [ 8 , 12 ]. Abnormal ECHO with left ventricle dysfunction was observed among 337 out of 823 (41%) patients [ 6 , 8 , 9 , 12 – 15 , 18 , 20 – 22 ].…”

“…Coronary artery abnormality was detected among 143 out of 802 (18%) patients [ 6 , 10 , 12 , 13 , 15 , 16 , 18 – 21 ], 19.4% (20 out of 103) had coronary dilatation [ 12 – 14 , 18 ], whereas aneurysm was seen in 17.8% (23 out of 129) patients [ 8 , 9 , 11 – 13 , 20 , 22 ]. Furthermore, 357 out of 725 (49%) patients presented with hypotension with shock [ 6 , 8 , 9 , 12 , 13 , 16 , 17 , 20 , 22 ] and 9% had congestive cardiac failure [ 6 , 13 , 16 , 17 , 21 , 22 ].…”

“…Patients with documented thrombosis or with coronary artery aneurysm and z score of ≥ 10.0 or an ejection fraction (EF) < 35% should receive enoxaparin in addition to low-dose aspirin [ 28 ]. Sixty-seven percent patients (505 out of 754) had elevated d -dimer [ 6 , 8 , 10 , 12 – 14 , 16 , 17 , 20 , 21 ], and 284 patients received antithrombotic therapy [ 6 , 9 , 11 , 13 , 14 , 16 , 20 , 21 ] in this review. Immunomodulators: Infliximab (anti-tumour necrosis factor drug), Anakinra, canakinumab (IL-1 receptor antagonist) and tocilizumab (IL-6 antagonist) are alternative options for treatment of MIS-C patients who are refractory to IVIG, have glucocorticoids with enlarging coronary aneurysm or in patients with contraindications to these treatments [ 30 ].…”