COVID-19: Pediatrics and Pregnancy

The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic.  The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target.  This post will serve as a summary of pediatrics and pregnancy in regards to COVID-19. 

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COVID-19 and Pediatrics:

Nationwide case series of 2143 patients with COVID-19 [2]

• 731 (34.1%) laboratory confirmed + 1412 (65.9%) suspected cases
  • Asymptomatic: 94 (4.4%)
  • Mild Case: 1091 (50.9%)
  • Moderate Case: 832 (38.8%)
  • All the above categories were essentially viral URI symptoms + no need for oxygen
  • >90% of patients were asymptomatic, mild, or moderate cases
• Proportion of severe/critical cases by years of age:
  • <1: 10.6%
  • 1 – 5: 7.3%
  • 6 – 10: 4.2%
  • 11 – 15: 4.1%
  • ≥16: 3.0%
  • One 14-year-old died, with no other deaths reported
• Authors speculate that children are less sensitive to SARS-CoV-2 because the maturity and function (i.e. binding ability) of ACE2 in children may be lower than adults
• Children of all ages appeared susceptible and suspected of person-to-person transmission (i.e. potential vector)

1391 children assessed and tested for SARS-CoV-2 [3]

• 171 (12.3%) confirmed to have SARS-CoV-2 infection
• Signs and Symptoms:
  • Cough: 48.5%
  • Pharyngeal Erythema: 46.2%
  • Fever: 41.5%
  • Diarrhea: 8.8%
• Diagnosis:
  • Asymptomatic infection = 15.8%
  • Upper respiratory tract infection = 19.3%
  • Pneumonia = 64.9%
• In contrast to adults infected children appear to have a milder course

Systematic review of all available evidence published on pediatric cases of SARS-CoV-2 from December 1^st, 2019 to March 3^rd, 2020 [6]

• Identified 815 articles, but only 18 studies (N = 1065) met eligibility criteria
  • <10 years: 444 patients
  • 10 to 19 years: 553 patients
  • All reports but 1 were based out of China
• Most patients had mild respiratory symptoms with fever and cough being the most reported symptoms
• Only 1 case of severe COVID-19 (13month old infant)
• No deaths were reported in children aged 0 to 9 years
• One death was reported in the age range of 10 to 19 years
• Bottom Line: Most children with COVID-19 present with mild symptoms, if any, generally require supportive care only, and typically have a good prognosis with recovery after 1 to 2 weeks

Kawasaki Disease [7][8]

• There are case reports of atypical Kawasaki disease and COVID-19 (i.e. association)
• Formal Criteria for Kawasaki disease:
  • Fever for 5 days + 4 out of 5 clinical criteria in the absence of an alternate diagnosis
    • Rash
    • Cervical lymphadenopathy (at least 1.5cm in diameter)
    • Bilateral conjunctival injection
    • Oral mucosal changes
    • Peripheral extremity changes
• Patients who do not meet the above Kawasaki disease definition but have fever and coronary artery abnormalities are classified as having atypical or incomplete Kawasaki disease
• Treatment:
  • IVIG 2g/kg x1 over 10 to 12hrs
  • ASA 20mg/kg QID until 48 to 72hrs after cessation of fever

Kawasaki Disease conjunctival Injection (Image from [7])

Kawasaki Disease Maculopapular Rash (Image from [7])

Kawasaki Disease Common Findings (Image from [8])

COVID-19 and Pregnancy

• Still need more follow-up studies to further evaluate the safety and health of pregnant women and newborn babies who develop COVID-19 infection
• Retrospective review of 9 pregnant patients with laboratory-confirmed COVID-19 PNA [1]
  • Vertical transmission was assessed by testing for the presence of SARS-CoV2 in amniotic fluid, cord blood, and neonatal throat swab samples
  • Breastmilk samples were also collected and tested from patients after the first lactation
  • All 9 mothers had Caesarean section in their 3rd trimester
  • 0/9 mother developed severe pneumonia, requiring mechanical ventilation or died of COVID-19 PNA
  • Fetal distress: 2/9
  • Premature rupture of membranes: 2/9
  • Fetal death: 0/9
  • All 9 births had 1-min Apgar score of 8 -9 and a 5 min Apgar score of 9 – 10
  • Amniotic fluid, cord blood, neonatal throat swab, and breastmilk samples tested from 6/9 patients and all samples tested negative for the virus (No vertical transmission)
• Retrospective observational cohort study of 33 neonates born to mothers with COVID-19 [4]
  • 3/33 (9%) neonates with confirmed COVID-19
  • NO DEATHS
• Retrospective observational study of 6 neonates born to mothers with COVID-19 [5]
  • Blood samples of IgM and IgG collected from mothers and newborns as well as throat swab samples from newborns
  • SARS-CoV-19 not detected in the serum or throat swab by RT-PCR in any newborns
  • IgG elevated in 5/6 newborns
    • IgG passed passively crosses placenta from mother to fetus
  • IgM detected in 2 newborns
    • IgM is not usually transferred from mother to fetus due to larger structure
      • Unclear if there was damage to placentas in this study
      • IgM could be produced by infant if virus crosses placenta
    • No cord blood, amniotic fluid or breast milk testing for SARS-CoV-2

The American College of Obstetricians and Gynecologists (ACOG) COVID-19 Recommendations [Link is HERE]

• • Very little is known about COVID-19 in regard to its effect on pregnant women and infants
  • Current limited data does not indicate that pregnant women are at increased risk of severe morbidity and mortality
  • Pregnant women are known to be at greater risk of severe morbidity and mortality from infections such as influenza and SARS-CoV
  • Preterm birth has been reported among infants born to mothers positive for COVID-19 during pregnancy, but this is based on limited data
  • There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended.  The primary concern with breast feeding is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.

ACOG Algorithm in Evaluation of Pregnant Patients with Known Exposure and/or Symptoms Consistent with COVID-19

The Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines (Link is HERE)

References:

1. Chen H et al. Clinical Characteristics and Intrauterine Vertical Transmission Potential of COVID-19 Infection in Nine Pregnant Women: A Retrospective Review of Medical Records. Lancet 2020 [Epub Ahead of Print]
2. Y Dong et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics 2020. PMID: 32179660
3. Lu X et al. SARS-CoV-2 Infection in Children. NEJM 2020. [Epub Ahead of Print]
4. Zeng L et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers with COVID-19 in Wuhan, China. JAMA Pediatrics 2020. [Epub Ahead of Print]
5. Zeng H et al. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA 2020 [Epub Ahead of Print]
6. Castagnoli R et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA Pediatrics 2020. PMID: 32320004
7. Jones VG et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr 2020. PMID: 32265235
8. McCrindle BW et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation 2017. PMID: 28356445

For More Thoughts on This Topic Checkout:

• REBEL EM: COVID-19 – The Novel Coronavirus 2019
• Don’t Forget the Bubbles: COVID 19 in Kids
• FOAMCast: COVID-19 – Pregnancy, Breastfeeding, and Investigational Treatments
• Don’t Forget the Bubbles: Acute COVID Management in Children – Evidence Summary
• Don’t Forget the Bubbles: The Missing Link? Children and Transmission of SARS-CoV-2
• FOAMCast: Pediatric Multisystem Inflammatory Syndrome Temporally Associated with COVID-19

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) and Mizuho Morrison, DO (Twitter: mizuhomorrison)