covid 19 in children

EPIDEMIOLOGY, INCIDENCE , pathophysiology,dignosis, investigations, vaccines, treatment, prevention

1. Covid-19 in Children Presented by Ali Faris Abdulbaqi Ruqaya Hussein Ali Hamed Mejbas Hasan Heidi Mohammed Dhia

2. EPIDEMIOLOGY OF COVID-19 Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 ( SARS-CoV-2 ) . The disease was first reported in December 2019 from Wuhan, Hubei province, China and has since spread throughout the world. WHO declared a global pandemic on March 11, 2020.

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4. COVID-19 “WHO wanted a name that doesn’t refer to a geographical location, animal, an individual or a group of people.” 5 CO – Corona VI – Virus D – Disease

5. Dec 31,2019, Clusters of cases pneumonia of unknown origin reported to China National Health Commission Jan 1 Seafood market closed Jan 5 WHO advised against travel restrictions Jan 11 first Coronavirus death reported March 24 First Death from IRAQ Feb 11, WHO gave name to new Coronavirus disease: COVID-19 Jan 12 Named as 2019-nCoV Whole genome sequence shared with WHO Feb 24 first case in Iraq/ Najaf March 11 WHO declare Pandemic 12 Jan 7 Novel Coronavirus isolated

6. Affected Country and Territory: 167 Confirmed cases:141 million Death:3 million Recovered:82, million 13

7. INCIDENCE OF COVID-19 IN CHILDREN Fewer cases of coronavirus disease 2019 (COVID-19) have been diagnosed in children than in adults, and the majority of the pediatric cases have been mild . The true incidence of SARS-CoV-2 infection in children is unknown , due to the lack of widespread testing and the prioritization of testing for adults and those with severe illness. Hospitalization rates in children are significantly lower than hospitalization rates in adults with COVID19, which suggests that children may have less severe illness from COVID-19 compared with adults.

8. PATHOPHYSIOLOGY less is known about the pathophysiology of COVID-19. SARS CoV-2 infection is characterized by an initial cytokine storm that can result in acute respiratory distress syndrome and macrophage activation syndrome. This initial phase is then followed by a period of immune dysregulation , which is the major cause of sepsis-related fatalities. differences between adult and pediatric disease are likely the result of changes within both immune function and the angiotensin-converting enzyme (ACE) 2 receptor , used by the virus to enter type II pneumocytes in the lung.

9. In the infection phase of COVID-19, this virus uses the enzymatic receptor of ACE2 to penetrate the host cell. Coronavirus binding with ACE2 has been shown to lead to a down regulation of ACE2. The decrease in ACE2 results in a lower conversion of angiotensin to angiotensin 1–7 vasodilator. Thus, decrease in the stability of the pulmonary endothelium and an aggravation of respiratory distress The profound lymphopenia seen in patients with COVID-19 is likely the result of T lymphocyte infection and death that occurs as SARS CoV-2 infects these cells.

10. As the infection progresses, with acceleration in viral replication and epithelial-endothelial injury, the inflammatory response is accentuated. Interstitial mononuclear inflammatory infiltrates and edema followed by hyaline membrane formation occurs leading to acute respiratory distress syndrome (ARDS) . These changes may be visible as ground glass opacities on a CT scans

11. Further injury to the endothelial tissues results in microthrombi formation and can lead to thrombotic complications such as pulmonary embolism , venous thrombosis , and thrombotic arterial complications as seen in severely ill patients. These complications have been seen more in adult than in pediatric patients, although they have been reported in the latter as well. Secondary sepsis in these individuals further contributes to the severety of the illness.

12. RISK FACTORS While all children are capable of getting the virus that causes COVID-19, they don't become sick as often as adults. Most children have mild symptoms or no symptoms. The main reported risk factors for the pediatric population to be infected with COVID-19 were close contact with a family member with an infection and a history of travel or residence in an endemic area.

13. But, children with underlying conditions, such as obesity , diabetes and asthma , are at higher risk of serious illness with COVID-19. Children who have congenital heart disease , genetic conditions or conditions affecting the nervous system or metabolism are also at higher risk of serious illness with COVID-19. Research suggests disproportionately higher rates of COVID-19 in Hispanic and non-Hispanic Black children than in non-Hispanic white children. Hispanic and non-Hispanic Black children also have had higher rates of hospitalization.

14. ROUTE OF TRANSMISSION 1. COVID-19 virus is primarily transmitted between people through respiratory droplets and direct contact with surfaces polluted with coronavirus. 2. Aerosol environmental generation by some medical procedures could be the cause of transmission like endotracheal intubation, resuscitation, and cardiopulmonary bronchoscopy, open suctioning, nebulization. 3. There have been no reports of faecal−oral transmission of the COVID-19 virus to date in spite of the finding of the virus in stool of patients.

15. Children of all ages can transmit COVID-19 to others, but the rate of transmission by young children is uncertain. Infected children shed COVID-19 virus with nasopharyngeal viral loads comparable to or higher than those in adult. Due to community mitigation measures and school closures, transmission of SARS-CoV-2 to and among children have been reduced in the United States during the pandemic. This may explain the low incidence in children compared with adults.

16. An important question that remains is whether COVID-19 can be transmitted from a pregnant woman to her fetus via vertical transmission? Some studies focused to investigate the possibility of intrauterine transmission of COVID-19 infection. They chose to test amniotic fluid, cord blood, and neonatal throat swab samples at birth to ascertain the possibility of intrauterine fetal infection.  The results show that SARS-CoV-2 was negative in all of the above samples, suggesting that no intrauterine fetal infections occurred as a result of SARS-CoV-2 infection during a late stage of pregnancy. It is important to remember that newborn infants can acquire an infection in other ways beyond intrauterine maternal-fetal transmission(birth canal، post-partum breast feeding، inhalation of the agent through aerosols produced by coughing from the mother..).

17. Clinical presentation of Covid-19 in children The incubation period of SARS-CoV-2 appears to be about the same for children as in adults, at 2- 14 days with an average of 6 days.10 symptoms of COVID-19. While children and adults experience similar symptoms of COVID-19, children's symptoms tend to be mild and cold-like. Most children recover within one to two weeks. Possible symptoms can include: Fever Nasal congestion or runny nose Cough Sore throat Shortness of breath or difficulty breathing Fatigue

18. Headache Muscle aches Nausea or vomiting Diarrhea Poor feeding or poor appetite New loss of taste or smell Belly pain Pink eye (conjunctivitis) Children infected with SARS-CoV-2 may have many of these non-specific symptoms, may only have a few (such as only upper respiratory symptoms or only gastrointestinal symptoms), or may be asymptomatic. The most common symptoms in children are cough and/or fever.

19. WHY DO CHILDREN REACT DIFFERENTLY TO COVID-19? The answer isn't clear yet. Some experts suggest that children might not be as severely affected by COVID-19 because there are other coronaviruses that spread in the community and cause diseases such as the common cold. Since children often get colds, their immune systems might be primed to provide them with some protection against COVID-19. It's also possible that children's immune systems interact with the virus differently than do adults' immune systems (as mentioned before in pathophysiology ). Some adults are getting sick because their immune systems seem to overreact to the virus, causing more damage to their bodies. This may be less likely to happen in children.

20. Although rare, children under age 1 appear to be at higher risk of severe illness with COVID-19 than older children. This is likely due to their immature immune systems and smaller airways, which make them more likely to develop breathing issues with respiratory virus infections. Research suggests that only about 2% to 5% of infants born to women with COVID-19 near the time of delivery test positive for the virus in the days after birth. However, if mother is severely ill with COVID-19, she might need to be temporarily separated from her newborn .

21. Diagnostic methods Preferred diagnostic test is Reverse transcriptase Polymerase chain reaction(RT PCR) for SARS CoV2 RNAdc. Preferred sample for children not receiving mechanical ventilation are upper respiratory tract sample (nasopharyngeal and oropharyngeal swab) these should be transported in viral transport media on(VTM) ice In mechanically ventilated children bronchoalveolar lavage or endotracheal aspirate would be the preferred specimen These have to be mixed with the viral transport medium and transported on ice . Sputum induction should be avoided in view of risk of aerosol generation

22. Laboratory studies Although a consistent pattern of characteristic laboratory findings has not yet been identified in children with confirmed COVID-19, the following abnormalities have been observed: Lymphopenia Increased levels of liver and muscle enzymes and lactate dehydrogenase Increased myoglobin and creatine kinase iso enzyme levels Elevated C-reactive protein (CRP) level Elevated erythrocyte sedimentation rate Increased procalcitonin level Elevated D-dimer Elevated levels of inflammatory factors such as interleukin (IL)-6, IL-4, IL-10, and tumor necrosis factor (TNF)-α

23. Blood SARS -CoV 2 antibody detection: Serum sARS CoV 2 specific antibodies IgM and IgG test positive for two consecutive times is helpful for diagnosis However,negative antibody tests cannot exclude infection at the early stage of disease onset . Non specific reactions must be ruled out for positive IgM antibody detection The diagnostic value of IgM and IgG detection needs further evaluation, because it takes a certain period for the body to produce serum specific antibodies and reach the detection threshold after virus infection and the kinetic features of serum specific antibody production after the virus infection are still unclear Antibody test can be used for retrospective auxiliary diagnosis and sero epidemiological surveys

24. Alterations in leukocyte indices appear to be mostly inconsistent in children,unlike the case of adults with COVID 19 Therefore, leukocyte indices in children do not appear to be reliable markers of disease severity Instead, serially monitor C reactive protein (crp)procalcitonintest (pct) and lactatedehydrogenase(LDH) levels, to monitor the course of the disease in children hospitalized with COVID 19.

25. Elevated Creatine kinase MB (CK MB) levels in children with mildCOVID 19 suggest the possibility of cardiac injury, highlighting the importanceof monitoring cardiac biomarkers in hospitalized patients and the need for further investigation. Rapid serology kits may not be positive during first 7–10 days of infection and stay positive for several weeks following infection

26. Imaging studies Imaging is not indicated for pediatric patients presenting with mild clinical symptoms unless the patient has risk factors for disease progression or develops worsening clinical symptoms. Sequential chest radiograph examinations, ordered on an as-needed clinical basis, are indicated for pediatric patients with COVID-19 to assess response to therapy, evaluate clinical deterioration, or assess the positioning of life support devices Post-recovery follow-up imaging is not recommended for asymptomatic pediatric patients with a mild COVID-19 disease course; however, it may be considered in asymptomatic individuals with an initial moderate-to-severe disease course or symptomatic individuals regardless of initial disease severity depending on the level of clinical concern for long-term lung injury.

27. Digital X ray photography x-ray photography is not recommended as the first choice,because it is easy to missed diagnosis Infected pediatric patients commonly have no abnormal X ray imaging results at the early stage of disease onset Only those severe cases or those at the progression stage show white lung pattern X ray photography. Common chest radiograph findings in children with COVID-19 pneumonia include bilaterally distributed peripheral and subpleural ground-glass opacities and consolidation.

28. A and B a fourteen-year-old boy with fever and cough. A. Chest x-ray shows diffuse areas of peri-bronchial thickening. There is slight predominance in the parahiliarregions. B. Magnified right lower lobe shows dense cuff surrounding an aerated bronchus. C. corresponds to a ten-year-old girl with patchy bilateral ground-glass opacities (arrows).

29. CT scanning Chest CT Scan: According to recent evidences the CT scan findings of COVID-19 pneumonia manifested as multifocal unilateral or bilateral ground glass opacity (GGO) to mixed GGO and consolidation mostly peripheral located. GGO are usually seen in the early days and progress to the consolidation in the following days. Lymphadenopathy is usually not seen and pleural effusion is rare and mild. In general, normal chests CT scan maybe helpful in rule out of COVID-19 . Indications of chest CT scan are: A) Bilateral lung involvement on CXR. B) ICU admission. C) In a patient who has not responded to primary treatment and is developing worse

30. CT scanning Chest CT Scan: According to recent evidences the CT scan findings of COVID-19 pneumonia manifested as multifocal unilateral or bilateral ground glass opacity (GGO) to mixed GGO and consolidation mostly peripheral located. GGO are usually seen in the early days and progress to the consolidation in the following days. Lymphadenopathy is usually not seen and pleural effusion is rare and mild. In general, normal chests CT scan maybe helpful in rule out of COVID-19.

31. TREATMENT Supportive Maintenance fluid (oral and/ or intravenous) and calorie intake. Antipyretics: paracetamol. Antibiotics (broad-spectrum) when secondary bacterial infection occurs. Oxygen supplementation in moderate to severe cases is aimed to prevent ARDS, organ failure, and secondary infection. Nasal high-flow oxygen therapy, and non-invasive or invasive mechanical ventilation should be undertaken when necessary. Steroids Steroid therapy is not indicated in majority of pediatric COVID-19 patients as they usually get well without severe complications

32. 3- Anticoagulant Malignancy, obesity, and chronic heart diseases may be significant risk factors for VTE. Enoxaparin prophylaxis is advised in children and adolescent confirmed COVID-19 cases. 4- Antiviral medications The safety and effectivity of antivirals for treating COVID-19 have not been approved yet. Examples of possible antivirals used in COVID-19 patients are lopinavir/ritonavir and favipiravir and remdesivir

33. 5- Convalescent plasma It has no official approval from (WHO). However, the administration of convalescent plasma in the early stage of severe COVID-19 disease has shown good recovery results.

34. Prevention Clean your hands often. Use soap and water, or an alcohol-based hand rub. Maintain a safe distance from anyone who is coughing or sneezing. Wear a mask when physical distancing is not possible. Don’t touch your eyes, nose or mouth. Cover your nose and mouth with your bent elbow or a tissue when you cough or sneeze. Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention. Calling in advance allows your healthcare provider to quickly direct you to the right health facility. This protects you, and prevents the spread of viruses and other infections. Wear a mask when going outside Follow the advice provided by your local health authority. Get vaccinated.

35. Vaccines The best COVID-19 vaccine is the first one that is available to you. Do not wait for a specific brand. All currently authorized and recommended COVID-19 vaccines: • are safe, • are effective, and • reduce your risk of severe illness.

36. Common side effects • A severe or persistent headache • Blurred vision • Chest pain • Shortness of breath • Swollen legs • Persistent abdominal pain • Unusual skin bruising • Pinpoint spots (not including the injection site)

37. AstraZeneca Vaccine Type: vector vaccine Protection: 76% efficacy, 100% against severe manifestation and death Possible side effects: Thrombotic events were reported rarely (a reaction similar to heparin induced thrombocytopenia)

38. Senopharm Vaccine Type: inactivated virus Protection: 79% efficacy, 100% against severe disease and death Side effects are milder

39. Pfizer/BioNTech's Vaccine Type: mRNA vaccine Pretection: 95% efficacy, 100% against severe disease and death

40. Why a vaccine for children will take longer? Kids weren’t involved in the original adult clinical trials because the data tells us that severe illness from COVID-19 tends to happen to adults (especially in older adults). We’re not seeing the same sort of response or sickness in children. One of the reasons for focusing on an adult version first is because when children are involved in clinical trials, there is oftentimes more layers of protection to go through. For instance, the child and both parents typically have to agree to participate in the trial or study. Immune systems in kids can vary greatly depending on age.

41. Thank you Any questions?