CMAAO IMA CORONA FACTS and MYTH BUSTER 95: COVID in CHILDREN

CMAAO IMA CORONA FACTS and MYTH BUSTER 95: COVID in CHILDREN

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Monica Vasudev

851: Children — Symptomatic infection in children appears to be relatively uncommon; when it occurs, it is usually mild, although severe cases have been reported

References

1.         Cui Y, Tian M, Huang D, et al. A 55-Day-Old Female Infant infected with COVID 19: presenting with pneumonia, liver injury, and heart damage. J Infect Dis 2020.

2.         Cai J, Xu J, Lin D, et al. A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clin Infect Dis 2020.

3.         Liu W, Zhang Q, Chen J, et al. Detection of Covid-19 in Children in Early January 2020 in Wuhan, China. N Engl J Med 2020; 382:1370.

4.         Qiu H, Wu J, Hong L, et al. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis 2020.

852:  Pediatric multisystem inflammatory syndrome associated with COVID-19 pandemic : Shares clinical features with Kawasaki disease (KD), KD shock syndrome, and toxic shock syndrome. Clinical features include persistent fever, gastrointestinal symptoms, hypotension, myocarditis, and elevated inflammatory markers (CRP, ferritin, D-dimers). 

853: Clinical features of COVID-19 in children: As of early April, children accounted for 1.7 percent of nearly 150,000 laboratory-confirmed cases of COVID-19 in the United States [1]. Among the few children with complete clinical data, the median age was 11 years (range 0 to 17 years); about 90 percent of cases were associated with household or community exposure. Fewer children than adults reported symptoms. Fever and cough were the most common symptoms in children. Infants <12 months and children with underlying medical conditions (eg, chronic pulmonary disease including asthma, cardiovascular disease, immunosuppression) were at increased risk for severe illness and should be monitored closely for progression of symptoms.

Reference: Weiss SR, Navas-Martin S. Coronavirus pathogenesis and the emerging pathogen severe acute respiratory syndrome coronavirus. Microbiol Mol Biol Rev 2005; 69:635.

854:   Children of all ages can get COVID-19, although they appear to be affected less frequently than adults.

855: COVID-19 in children is usually mild. The most common symptoms in children are fever and cough. Other symptoms include sore throat, fatigue, rhinorrhea/nasal congestion, diarrhea, and vomiting. Additional symptoms that have been reported in adults include chills or shaking chills, myalgia, headache, and new loss of taste or smell. Laboratory findings are often normal but may include leukopenia, lymphocytopenia, and elevated procalcitonin or C-reactive protein.

855:  Children with COVID-19 and severe or critical lower respiratory tract disease generally require hospital admission. Severe disease is defined by a new requirement for supplemental oxygen or increased requirement from baseline without new or increased need for ventilatory support (noninvasive or invasive). Critical disease is defined by new or increased need for noninvasive or invasive mechanical ventilation, sepsis, multiorgan failure, or rapidly worsening clinical trajectory.

856: Supportive care (eg, respiratory support, fluid and electrolyte support, monitoring for cytokine release syndrome) is the mainstay of therapy for children with severe or critical COVID-19.

857: Recommendations from the multicenter initial guidance on the use of antiviral agents for children with COVID-19 and other experts that antiviral therapy for COVID-19 should occur in the context of a clinical trial.

858: Decisions regarding antiviral therapy should be individualized according to disease severity, clinical trajectory, and underlying conditions that may increase the risk for progression. When a decision is made to use antiviral therapy, prefer remdesivir to other agents. Hydroxychloroquine (without azithromycin) is an alternative for children who are not candidates for remdesivir or if remdesivir is unavailable.

859: Children with documented or suspected COVID-19 and mild symptoms (eg, fever, cough, pharyngitis, other respiratory symptoms) generally should be managed at home unless they have a chronic condition that increases their risk of severe disease. Management is focused on prevention of transmission to others (ie, isolation), monitoring for clinical deterioration (eg, difficulty breathing, cyanosis, symptoms of shock), and supportive care.

860: Symptomatic care for COVID-19 in the outpatient setting is similar to that for other upper respiratory or gastrointestinal clinical syndromes.

861: Prevention of transmission focuses on hygiene and social distancing.

862: Hand sanitizer safety: Although washing hands with soap and water, when available is preferred for hand hygiene, alcohol–based hand sanitizer is safe for use in children. However, because ingestion of even a small amount of liquid hand sanitizer can cause alcohol poisoning in children (including hypoglycemia), children younger than six years should be supervised when using alcohol-based hand sanitizers, and alcohol-based hand sanitizers should be kept out of the reach and sight of children.

863:  Should play dates and playgrounds be avoided? — Given the possibility of transmission from asymptomatic individuals (or presymptomatic individuals within the incubation period) CDC recommends that children not have play dates with children from other households and that when playing outside, they remain ≥6 feet from people from other households

864: Use of cloth face masks — The CDC recommends that individuals ≥2 years of age wear a cloth face covering (eg, homemade masks or bandanas) when they are in public settings where social distancing may be difficult to achieve (eg, grocery stores, clinician offices), especially in areas with substantial community transmission. Cloth masks are not recommended for children <2 years of age because of concerns about suffocation.

865: Hygiene and social distancing

Having friends or family members bring necessary items to the home (to be retrieved outside)

Having the child (and other sick family members) wear a mask if leaving the home cannot be avoided. At the time of discharge, if supplies allow, providing patients with a pair of gloves and several masks may help to prevent transmission to household contacts. In addition, for patients without access to private transportation, arranging medical transportation, if possible, is preferable to the use of public transportation or ride-sharing services to minimize exposure to the public.

As much as possible, keeping ill family members ≥6 feet away from other people, especially family members who are ≥65 years of age or have serious medical conditions

If such separation is not possible, have the ill family member wear a facemask when they are in the same room or vehicle as other people.

Keeping ill family members separated from pets in the household

Having family members who have fever or cough sleep in separate rooms and use separate bathrooms

Avoiding sharing items (eg, pillows, blankets, utensils, cups)

866: The age distribution of cases in the United States was as follows

<1 year – 15 percent

1 to 4 years – 11 percent

5 to 9 years – 15 percent

10 to 14 years – 27 percent

15 to 17 years – 32 percent

Although infants <1 year of age accounted for 15 percent of confirmed cases, the proportion of all cases that have occurred in infants (0.27 percent) is less than the proportion of the United States population that is <1 year of age

MMWR Morb Mortal Wkly Rep. 2020;69(14):422.

Moderate-to-Severe COVID 19 in children

Moderate-to-Severe COVID 19 in children

Dr KK Aggarwal

President CMAAO, HCFI and National President IMA

A study of six young children in Wuhan, China, hospitalized with COVID-19 found that four of them developed pneumonia, with a median hospital stay of seven days. The findings showed abnormal lab results, including low levels of lymphocytes for all six children ages 1 through 7, with six patients presenting with fever and cough, and four of six presenting with vomiting. Moreover, one child was admitted to the pediatric intensive care unit and received pooled immune globulin, the authors wrote in the New England Journal of Medicine.

But infections in children did not seem to figure into recent guidance for mitigating COVID-19 spread in New Rochelle, New York, where substantial local transmission was underway. It did not recommend closing schools, but only "social distancing measures," such as cancelling large gatherings, postponing athletic contests, and limiting "classroom mixing." Distance learning was recommended only for students "at risk of severe illness."

The authors examined data from a larger cohort of 366 hospitalized children age 16 and younger, from Jan. 7 to Jan. 15, 2020. There were 23 testing positive for influenza A, 20 for influenza B, and six for COVID-19.

Source Reference: Liu W, et al "Detection of Covid-19 in Children in Early January 2020 in Wuhan, China" N Engl J Med 2020; DOI: 10.1056/NEJMc2003717.

Disposing Face Masks

Ministry of Health and Family Welfare Guidelines on disposal of used masks by public: Masks used by patients / care givers/ close contacts during home care should be disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep burial.  

Chaotic household, a risk factor for poor asthma control in children

Dr KK Aggarwal

A chaotic household, which lacks organization and routine, is noisy and where relaxation is difficult, is a risk factor for worse asthma outcomes in urban minority children, suggests results from the Asthma Action at Erie Trial published in the July 2019 issue of the journal Pediatrics. Along with this, depression in the child and the parent was also identified as a risk factor.  

Researchers analyzed the association between parent, child and family functioning and child asthma control in urban minority youth with uncontrolled asthma. Family chaos was evaluated using a 15-item questionnaire that asked respondents to rate statements such as "No matter how hard we try, we always seem to be running late;" "We can usually find things when we need them;" "We always seem to be rushed;" and "Our home is a good place to relax." The relationship between parent depression and post-traumatic stress disorder (PTSD) symptoms and child depression and PTSD symptoms was also examined.

Parent and childhood depressive symptoms, but not PTSD symptoms, were associated with worse child asthma control. Higher levels of family chaos were found to be associated with worse child asthma control even when the researchers controlled for parent and child depression. The study concluded that family chaos may explain the association of parental depression and child asthma control.

This study adds to the list of evidence, which shows that social factors “social determinants of health” also influence the health outcomes. Conditions we live in and work also affect our health.

These social determinants of health have rightly been called “the causes of the causes”, which implies that to eliminate a problem, its root causes must be addressed first. Effective care cannot be delivered, if these factors are not taken into consideration.

So, treat not just the disease, but the individual patient in context of his/her social circumstances.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Drinking water reduces intake of sugary beverages by children

Children and young adults who do not drink water during the day drink more sugary beverages and thus consume more calories from these sugary drinks, suggests a new study published April 22, 2019 in JAMA Pediatrics. Plain water was defined in the study as tap or nonsweetened, noncarbonated bottled water. 

Sugar-sweetened beverages (SSBs) includes soda, sweetened fruit juices, sports drinks, energy drinks, and sweetened tea and coffee drinks. They do not include 100% fruit juices, drinks sweetened with zero-calorie sweeteners, or drinks that are sweetened by the consumer, like coffee or tea brewed at home.

Analysis of data from the 2011-2016 National Health and Nutrition Examination Survey revealed that on a given day, about 20% of children reported drinking no water. No water intake was associated with intake of 92.9 kcal and 4.5% more calories from SSBs among participants aged 2 to 19 years. Additionally, those children consumed 200 calories from SSBs compared to children who did drink water.

Although the study did not establish causality, the message from the study is clear; sugar-sweetened beverages are not a substitute for water.

(Source: JAMA Pediatrics, April 22, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Landmark PALISADE trial brings hope for children with peanut allergy

Peanut allergy is a severe and potentially life-threatening food allergy. But, the landmark phase 3 PALISADE trial published Nov. 22, 2018 in the New England Journal of Medicine has provided a breakthrough and brought hope for children and adolescents who have peanut allergy.

The trial showed that oral immunotherapy resulted in higher doses of peanut protein that could be ingested without dose-limiting symptoms and in lower symptom severity during peanut exposure at the exit food challenge than placebo.

Researchers from Evelina London Children's Hospital and King's College London screened 551 participants with peanut allergy for the trial; of these, 496 were aged 4 to 17 years, who were randomly assigned, in a 3:1 ratio, to receive placebo or AR101, a peanut-derived investigational biologic oral immunotherapy drug in an escalating-dose program. Doses were gradually increased every two weeks for a period of six months, before continuing on a "maintenance dose" of peanut for a further six months.

The results showed that 67.2% (250/372) of those on AR101 treatment were able to ingest a dose of at least 600 mg of peanut protein (a whole peanut kernel contains approximately 250–300 mg of peanut protein), without dose-limiting symptoms, at the exit food challenge as compared to only 4.0% (5/124) of the placebo-treated participants.

Adverse events were seen in 95% of participants in both groups.

AR101 also showed a favorable safety profile. The maximum severity of symptoms was moderate in 25% of those in the active-drug group and 59% of the participants in the placebo group and severe in 5% and 11%, respectively, during the exit food challenge.

A total of 34.7% of the participants in the active-drug group had mild events vs 50.0% of those in the placebo group; 59.7% and 44.4% of the participants, respectively, had moderate grade events and 4.3% and 0.8%, respectively, had severe grade events.

Efficacy was not shown in the participants 18 years of age or older.

(Source: PALISADE Group of Clinical Investigators. AR101 oral immunotherapy for peanut allergy. N Engl J Med. 2018 Nov 18. doi: 10.1056/NEJMoa1812856. [Epub ahead of print]

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Emedinews: Breaking News: Infliximab for Children with Ulcerative Colitis

An US FDA advisory panel has recommended infliximab to include in the treatment of ulcerative colitis in children.

Dr KK Answers: At what age BP should be checked in children?

The Cardiovascular Control Program of the Ministry of Health has recommended that all children (above age 4) should have yearly blood pressure measurements. Early detection of high blood pressure has been shown to improve the healthcare of the children.