COVID-19 Cross Continuum Pediatric Topics


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A year after the COVID-19 pandemic, it is fair to say that children transmit the virus, but at lower rates, said Philip Zachariah, MD, of Columbia University, New York, in a presentation to SHM Converge, the annual conference of the Society of Hospital Medicine.

Zachariah stressed that supportive care remains a key element in the treatment of children with COVID-19. His presentation on pediatric hot topics at COVID-19 addressed several issues, including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID- 19.

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of the disease is diverse, Zachariah said.

COVID-19 presentations in children include those who are older and / or have comorbidities and present mainly respiratory problems, those who are younger with overlapping symptoms. Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate of children with COVID-19 is about 5%, but once hospitalized, ICU admission rates are about 30% and reflect the rates observed in adult patients, Zachariah noted.

Overall, the data show that underlying conditions are more common in acute cases of COVID-19 and that laboratory abnormalities are more pronounced in patients with MIS-C, he said.

According to the most recent studies, independent risk factors for acute COVID-19 in children include age groups (childhood or adolescence), minority populations, obesity, medical complexity, immune compromise and asthma.

However, data are limited on specific issues of medical complexity and the risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Zachariah noted.

Zachariah noted that another dilemma is recognizing MIS-C in a feverish child. A complex question, “but persistent high fever in the context of recent known COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If you had the opportunity to do a blood test, I would suggest you do a PCR [C-reactive protein] as a screening test, “Zachariah said. The best laboratory prognoses appear to be lymphopenia and cerebral natriuretic peptide (BNP) added.

A final risk factor is innate immune defects that could predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, Zachariah said.

“For example, autoantibodies against type 1 interferon production can suffer from serious diseases,” he noted. Patients with MIS-C have shown T cell activation patterns similar to those observed in severely ill adults and CX3CR1 + CD8 + vascular patrol T cell activation appears as a distinctive feature in MIS-C, explained.

Prevention plans with monoclonal antibodies

Another hot topic of pediatric COVID-19 is the prevention of serious illness and hospitalization through currently available therapies, Zachariah said. However, when interpreting efficacy data, doctors almost always extrapolate the relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but efficacy data are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which will ideally “provide protection to high-risk” populations “in the early stages of infection,” he said.

Bamlanivimab / etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the SARS-CoV-2 spike protein binding domain,” Zachariah said. In a study of 1,035 patients with a mean age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab 3 days after a positive COVID-19 test showed a 70% reduction in the risk of hospitalizations or COVID death. -19.

For children, the authorization for emergency use of current food and drug administration for the use of monoclonal antibodies covers patients 12 to 17 years of age who weigh 40 kg or more and meet any of the others. criteria: a body mass index of the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory diseases that require daily control, diabetes or chronic kidney disease, Said Zechariah.

In addition, pediatric patients 12 to 17 years of age could be considered for the treatment of monoclonal antibodies in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for symptoms of COVID -19 and has no new oxygen requirements, he said.

More information about MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Zachariah said. In addition, a to study published a JAMA On February 1, 2021, he showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared with IVIG alone in 111 children with a mean age of 8.6 years.

Although comparative efficacy data are lacking, in long-term follow-up, it appeared that all patients were doing well, Zachariah said. They include potential second-line therapies for atypical MIS-C anakinra i tocilizumab, added.

Zachariah concluded by highlighting the potential of COVID-19 vaccines, with ongoing studies for both Modern and Pfizer vaccines in children under 16 years of age.

Zachariah had no relevant financial conflict to reveal.

This story originally appeared on The Hospitalist in collaboration with MDedge News, which is part of the Medscape professional network.

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