INTRODUCTION

Coronavirus disease 2019 (COVID-19) is caused by a corona virus which is a double stranded RNA virus belonging to family of Coronaviridae.^{1, 2, 3} The previous two epidemics related to this family of viruses were SARS and MERS which emerged in 2003 and 2013 respectively. SARS is an airborne virus spread through respiratory droplets like influenza. It can also spread through surfaces which the infected person has touched.^{4, 3} It primarily affected adult and aged population 25-70 years with a case fatality rate of around 3%.⁴ The Covid-19 infections were first reported in Wuhan province of China in late 2019 and the initial cases were linked with Huanan seafood wholesale market. These patients presented with pneumonia of unknown origin.⁵ The disease spread rapidly after its initial reports in China and by April 2020, more than 210 countries around the world had seen the cases. WHO reported over one million confirmed cases and above 50 thousands death across the globe in April 2020.⁶ The World Health Organization declared Covid-19 a public health emergency of international concern (PHEIC) with highest level of alarm, and declared it a global pandemic.⁷

The Covid-19 is relatively uncommon in the pediatric population. Data from China’s Disease and Control Centre shows that there were 416 pediatric cases(i.e. 1%)under 10 years of age out of 72314 cases.⁸ An Italian survey shows pediatric patients to account for 1.8%.⁹ A U.K based study showed 18.1%cases below 1 year of age.¹⁰ In another study infants less than 3 months accounted for 18.8% of the cases.¹¹ Although the disease is not common in pediatric population the disease however is well reported in all pediatric age groups.¹² Overall severe disease and mortality in pediatrics is low.¹³ Severe disease has also been reported in infants under 1 year of age.¹⁴

Frequency of Covid-19 cases and hospitalization has been found to be high in infants compared with the rest of paediatric age group.¹⁵ Covid-19 cases have been reported from newborns to 14 years of age with 70% cases below 3 years of age.¹²

The clinical spectrum in children range from mild to severe disease. In children, many of the patients are asymptomatic and can carry out routine daily life activities without showing overt symptoms.⁸ Some patients also reported with fits.¹³ Gastrointestinal symptoms are also reported in children which include vomiting and diarrhea but this was reported in less than 10 percent of the pediatric cases.¹⁰

The aim of the study was to determine epidemiological characteristics, clinical spectrum and outcomes of Covid-19 in children presenting in Benazir Bhutto Hospital (BBH) Rawalpindi. The study is important as there is a wide variation of disease presentation and severity from region to region in the world. The study will give insight to the Covid-19 cases amongst children in Pakistan.

METHODS

During the epidemic, BBH Rawalpindi which is affiliated with Rawalpindi Medical University Rawalpindi played an important role in care of Covid-19 patients. The pediatric patients presenting with Covid-19 infection were managed with special arrangements made within the paediatric unit, with establishment of isolation wards, ICU and HDU. During the epidemic, patients with ages from new born to 12 years were admitted. These patients were managed as per protocols defined. Medical records of these patients were retrieved for this research. The criteria for selection of cases were patient with strong clinical suspicion of Covid-19. Only three patients turned out to be negative on PCR but were managed as Covid-19 as clinical assessment, laboratory and radiological findings were strongly suggestive of Covid-19. Patients with incomplete record were excluded from the analysis. A total of 50 patients who were hospitalized were included in the study. Ethical clearance was sought including permission from the Medical Superintendent for obtaining data. Data was collected on age, gender, clinical presentation, complications and outcomes of the disease.

RESULTS

The study included 50 patients of the pediatric age group. Majority of the hospitalized patients 31 (62%) were less than 1 year of age. Male patients were slightly more 28(56%) while female patients were 22 (44%).

Table 1. Age and gender of the subjects

Comorbid conditions were present in 15 (30%) of the patients. Among comorbid conditions, 7 patients had congenital heart disease, 3 patients had measles, 2 patients had asthma, 2 patients had acute lymphoblastic lymphoma and one patient had meningitis.

None of the patients in our study had history of travel to the affected areas and countries. Contact history was seen in 16 (32.7%) of the subjects. Implying community spread of the disease.

In our study majority of the children 41 (82%) presented with fever, cough 37 (74%) and shortness of breath 31 (62%). Amongst intestinal symptoms loose motions were present in 8 (16%) of the patients and poor oral intake/ anorexia was present in 18 (36%) of the patients.

Table 2. Clinical symptoms observed in patients.

In our study PCR was positive in 47 (94%) of the patients. 3 (6%) were PCR negative and were diagnosed clinically and with the help of CT scan findings.

Table 2. Clinical PCR Results.

X-ray chest changes were present in 44 (88%) of the patients. 34 (68%) of the patients had bilateral infiltrates. Lobar consolidation was seen in 5 (10%) of the patients. Chect X-rays of 6 (12%) of patients were normal.

Table 3. X-ray findings in study subjects

Complications developed in patients included congestive cardiac failure (CCF) 5 (10%), Acute respiratory distress syndrome (ARDS) 5 (10%), multi organ failure (MOF) 5 (10%), septicaemia/septic shock 15 (30%), septic shock 10 (20%), disseminated intravascular coagulation (DIC) 5 (10%), respiratory failure 12 (24%).

In our study 37(74%) patients showed complete recovery, while 13(26%) patients succumbed to their illness. Most of the mortality occurred in infants less than one year of age, accounting for 8 of the 13 deaths (61.5%). Four deaths were reported in children 1-5 years of age, while one 10 year old child died. All patients who died had developed complications including CCF, respiratory failure, septic shock, etc.

Table 4. Details of patients who died of Covid-19 complications in the study

DISCUSSION

Covid-19 in pediatric population has been under intense discussion as the disease became pandemic and spread across large parts of the world. It was thought that the children were less likely to get Covid-19 infections compared to adult. One reason was that children are less exposed to outside world. However new data suggests that the pediatric population is also vulnerable to Covid-19 just like the adult population and serious disease has been reported.^{14, 15} Although it is found that more than 90 percent of the infections in children are mild or asymptomatic, severe disease is not uncommon in children and infants with those less than 1 year of age being particularly at risk.¹⁶

In our study 31(62%) of the patients were less than one year. A study done on Covid-19 hospitalized patients showed that children less than 3 months accounted for 18.8 % patients with 27% of the children being less than 12 months.¹¹ A study in china showed that critically sick patients accounted for 10% of children less than one year of age and this was highest in any age category of the pediatric population.¹⁶ This consistent with our findings that infants are at a particularly high risk of Covid-19 infections and complications.

In our study none of the patients had travel history to the affected area, while contact history was present in 16 (32%) of the patients. In a study from China, 65 % of child cases had contact history in a close family member.¹²

In our study 56% of the patients were male and 44% were female. This is similar to other studies where boys were marginally more than girls (56.6% vs. 43.4%) 16 in affected pediatric cases.

In our study 15(30%) of the patients had underlying health conditions ,similar to a study from United States which showed that 42.3% patients had one or more related health disorder. However, underlying health conditions found in that study were different from those in our study. In our study congenital heart diseases was most common, seen in 7 patients. In the study from United States obesity (37.8%), chronic lung disease (18.0%), and prematurity (gestational age <37 weeks at birth), (15.4%) were the predominant co morbid conditions reported.¹¹

44(88%) of the patients had radiological changes in X-ray chest. The major finding noted in chest radiographs where bilateral infiltrates seen in 34(68%). The chest radiographs were normal in 6(12%) of cases. In our study chest radiographs were ordered in all patients. Our study also described the similar findings of bilateral infiltrates, being the main radiological findings, seen in 24(48%) of the patients.¹¹

In our study, the most common presenting symptoms were fever (82%) and cough (74%).Sore throat was less frequent as a presenting feature. An Italian study in the pediatric population showed that 82.1% of patients had fever and 48.8% had cough15. A China based study showed that 60 % patients had fever and cough was present in 65%¹².

Gastrointestinal symptoms in our study were diarrhea 16%, anorexia / poor oral intake 36%. A study in china showed that 8.8% of the patients had loose motions.¹² A Mexican study showed that 24%of their patients had gastrointestinal symptoms.¹⁰

In our study mortality was seen in 13(26%) of the patients. Mortality observed in our study is relatively high. Severe disease with hospitalization is reported in pediatric patients in different studies but the mortality was reportedly low.^{11, 17} American CDC data suggested that from January to October 2020, among 207,836 deaths reported, 87 deaths were reported in 5-18 years of age, while 40 deaths were reported in 0-4 years of age.¹⁸ In our study, most of the deaths were below one year of age. All children who died developed complications like respiratory failure, septicemia/septic shock, and multi organ failure.

As seen in our study there is broad range of clinical presentations and complications. Our study will therefore help in assessment, early suspicion, diagnosis and management of Covid-19 infection

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