Francisco Gonzalez, MD and Noah Kondamudi, MD, MBA, FAAP, FACEP
This article is intended to be a brief primer about COVID-19 illness among children with a focus on emergency department management. For readers that would like more in depth information, we refer them to these recently published review articles [1, 2, 3]
So far, over 3.4 million cases of pediatric COVID-19 cases have been reported in the U.S for a prevalence of 4525/100,000 children, out of which approximately 0.1-2.2% resulted in hospitalization and 0.04% resulted in death4. As cases of SARS CoV-2 infections continue to overwhelm hospitals and emergency departments around the country, it is important for emergency physicians to recognize signs and symptoms of this disease, cohort cases to avoid endangering staff and other patients, distinguish which individuals require testing, and ultimately manage them appropriately.
Prior to evaluation by the emergency physician, appropriate cohorting should be performed by implementing a questionnaire assessing for exposure to positive cases, travel to high prevalence areas, and common symptoms. If positive, patient should be placed in isolation in a negative pressure room. Appropriate personal protective equipment (PPE) should be worn (ie, isolation gown, facemask, face shield, goggles, gloves).
The clinical spectrum of SARS-CoV-2 infection in children is broad. Experience in the US, China, and Italy indicated that most pediatric patients with positive COVID-19 polymerase chain reaction (PCR), around 80%, are either asymptomatic or present with mild disease [6, 7, 8]. Fever was the most common presenting symptom, with approximately half of children with positive SARS-CoV-2 PCR, experiencing elevated temperature, followed by cough, decreased oral intake, and shortness of breath. It is important to recognize that close to 10% of pediatric patients presented without the typical respiratory manifestations, exhibiting mostly gastrointestinal symptoms such as diarrhea, and 5% experienced abdominal pain. Loss of sense of taste or smell is not as prevalent in the pediatric population as it is in adults. Less common symptoms include headaches, myalgia, fatigue, odynophagia, rhinorrhea, and nasal congestion.
Testing for COVID-19 should be performed, taking into account patient’s presenting symptoms, disease prevalence in the community, emergency department capabilities, and potential exposure to the virus. Up to 90% of pediatric cases report known exposure to an individual with COVID-19 8. There are two broad types of tests available: 1) viral tests to diagnose acute diseases and 2) antibody tests that offer insight into whether there has been a past infection. Viral tests involve obtaining a nasopharyngeal swab or a saliva sample for nucleic acid amplification tests (NAATs) and antigen assays. NAATs have higher sensitivity and typically have a longer turnaround time than an antigen test. Antibody or serologic testing is not helpful in diagnosing acute COVID-19 and should not be used as first line in the acute setting.
Testing should be performed on any patient with COVID-19 symptoms, particularly those with known close contact with someone with confirmed COVID-19. Symptomatic patients with a positive antigen test or NAAT should be considered true positives. When there is high clinical suspicion and antigen test results are negative, consider confirmatory testing with NAAT. Viral testing for SARS-CoV-2 should be included in every neonatal sepsis evaluation.
Management of COVID-19 is mainly symptomatic and depends on the severity of the disease and risk factors that can predict complications and sequelae. Risk factors that predict worse prognosis among children include young age (<1 year) and presence of pre-existing conditions, such as asthma, immunosuppression, chronic lung disease, diabetes mellitus, or cardiovascular disease. The pediatric emergency physician should evaluate the patient with particular attention to oxygen saturation, respiratory distress/failure, superimposed pneumonia, and hydration/dehydration status, which are the main reasons for admission for children with severe COVID-19 illness in pediatrics. In mild to moderate cases, COVID-19 specific testing is sufficient and a patient can be discharged home with symptomatic management. Acetaminophen is deemed safe to manage fever in pediatric COVID-19 illness. The use of ibuprofen is not associated with worse clinical outcomes in adult studies; however, limited data exists involving pediatric patients. In moderate to severe cases that need hospitalization, lab studies that include complete blood cell count, basic metabolic panel, inflammatory markers, blood culture, and chest x-ray are warranted. The first line use of antibiotics should be determined on a case by cases basis and be reserved for presumptive sepsis management when there is high suspicion of bacterial superinfection or co-infection.
Children discharged from the ED that are positive for COVID-19 or deemed positive (an individual with highly suggestive clinical presentation and symptoms, awaiting confirmatory test results) should be instructed to isolate at home. Isolation can be discontinued when all the following criteria have been met: a period of 10 days since the appearance of first symptoms has elapsed; has remained without fever for 24 hours without antipyretic use; and other COVID-19-related symptoms have shown improvement. If a patient tests positive but has minimal symptoms, they can discontinue isolation 10 days after the positive viral test.
In summary, COVID -19 illness in pediatric patients is predominantly asymptomatic, but can be varied. Most patients will present to the ED with fever or respiratory symptoms, and some can present with gastrointestinal symptoms. Appropriate precautions to isolate these patients and appropriate use of PPE by the ED provided team is essential. Shortness of breath with respiratory distress and hypoxia will need stabilization in the ED and hospitalization to an appropriate level. The American Academy of Pediatrics (AAP) strongly recommends in person learning in schools due to a variety of reasons, but acknowledges that the decision to open should be based on the joint guidance of local and state public health authorities and school administrators based on current virus epidemiology in the community. The pediatric emergency physician should have a high index of suspicion in order to recognize atypical presentations.
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2. Munro APS, Faust SN. COVID-19 in children: current evidence and key questions. Curr Opin Infect Dis. 2020 Dec;33(6):540-547. doi: 10.1097/QCO.0000000000000690. PMID: 3302718
3. CDC. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html. Accessed 3/29/21
4. Children and COVID-19: State-Level Data Report. Available from: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/.
5. Using Personal Protective Equipment (PPE). Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html.
6. Leidman, E., et al., COVID-19 Trends Among Persons Aged 0-24 Years – United States, March 1-December 12, 2020. MMWR Morb Mortal Wkly Rep, 2021. 70(3): p. 88-94.
7. Parri, N., M. Lenge, and D. Buonsenso, Children with Covid-19 in Pediatric Emergency Departments in Italy. New England Journal of Medicine, 2020. 383(2): p. 187-190.
8. Lu, X., et al., SARS-CoV-2 Infection in Children. New England Journal of Medicine, 2020. 382(17): p. 1663-1665. 9. COVID-19 Testing Overview. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html.
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12. Pathak, E.B., et al., COVID-19 in Children in the United States: Intensive Care Admissions, Estimated Total Infected, and Projected Numbers of Severe Pediatric Cases in 2020. Journal of Public Health Management and Practice, 2020. 26(4).
13. Rinott, E., et al., Ibuprofen use and clinical outcomes in COVID-19 patients. Clin Microbiol Infect, 2020. 26(9): p. 1259.e5-1259.e7.
14. Discontinuation of Isolation for Persons with COVID-19 Not in Healthcare Settings. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html.
15. American Academy of Pediatrics. COVID-19 planning considerations: Guidance for school re-entry. 2020 Jun 25; [e-pub]. (https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-educatio