What are the signs and management of COVID-19 in pediatric patients?

Signs of COVID-19 in Pediatric Patients

The vast majority of children with COVID-19 present with mild symptoms and have excellent outcomes, with fever (47.5%) and cough (41.5%) being the most common presentations, though up to 14-36% may be completely asymptomatic. 1, 2

Common Clinical Presentations

Typical Symptoms

• Fever is the most prevalent symptom, occurring in 47.5% of pediatric cases 2
• Cough follows as the second most common symptom at 41.5% 2
• Nasal symptoms (congestion, runny nose) occur in 11.2% of cases 1, 2
• Fatigue is present in 38.5% of patients and is an independent predictor of severe disease (OR = 2.505) 3, 4
• Gastrointestinal symptoms including diarrhea (8.1%) and nausea/vomiting (7.1%) may occur with or without respiratory symptoms 1, 2, 5
• Headache occurs in 7.2% of cases 6, 3

Atypical Presentations to Recognize

• Loss of taste (ageusia) and loss of smell (anosmia) are stronger predictors of COVID-19 than fever itself, occurring in 88.8% and 85.6% of cases respectively 3, 7
• "COVID toes" (chilblain-like lesions) may present as an atypical dermatologic manifestation 7
• Croup-like symptoms can occur in pediatric patients 7
• Sore throat is present in 5.1% of cases 3

Disease Severity Classification

Severity Distribution

• Asymptomatic: 14.2% of cases 2
• Mild disease: 36.3% (non-pneumonia symptoms) 2
• Moderate disease: 46.0% (pneumonia without severe complications) 2
• Severe disease: 2.1% (dyspnea, respiratory rate ≥30/min, oxygen saturation ≤93%) 1, 2
• Critical disease: 1.2% (respiratory failure, shock, multiorgan dysfunction) 1, 2

Age-Specific Considerations

• 82.2% of hospitalized pediatric patients are under 3 years of age 4
• Children aged 1-1.5 years warrant particular attention as all fatal cases in recent cohorts involved this age group with acute necrotizing encephalopathy (ANE) 4

Red Flags Requiring Immediate Evaluation

Respiratory Criteria by Age

Rapid respiratory rate thresholds indicating pneumonia 1:

• <2 months old: ≥60 breaths/min
• 2-12 months old: ≥50 breaths/min
• 1-5 years old: ≥40 breaths/min
• >5 years old: ≥30 breaths/min

Indications for Hospital Admission

Children should be admitted if they display any of the following 1:

• Abnormal vital signs (tachycardia, tachypnea)
• Respiratory distress of any severity
• Neurologic deficits or altered mental status (including subtle manifestations like confusion)
• Evidence of renal or hepatic injury (even mild)
• Marked inflammation (CRP ≥10 mg/dL)
• Abnormal cardiac markers (elevated BNP or troponin T) or abnormal EKG findings
• Shock, significant respiratory distress, or features of Kawasaki disease

Warning Signs of Severe Disease

• Hoarseness is an independent predictor of severity (OR = 2.781) and frequently observed in severe cases 4
• Dyspnea is associated with severe COVID-19 (OR = 2.43) 3
• Neurological symptoms (confusion, altered mental status) may indicate cerebral complications requiring urgent imaging 6

Multisystem Inflammatory Syndrome in Children (MIS-C)

Key Clinical Features

MIS-C is a rare but serious post-infectious complication occurring 2-6 weeks after SARS-CoV-2 infection 1:

• Persistent fever (≥38.5°C for ≥24 hours)
• Multiorgan involvement affecting at least 2 systems
• Mucocutaneous findings: rash, bilateral conjunctivitis without exudate, oral changes (red/cracked lips, strawberry tongue), swollen hands/feet 1
• Gastrointestinal symptoms: abdominal pain, diarrhea, vomiting 1
• Cardiac involvement: myocardial dysfunction, pericarditis, coronary abnormalities 1
• Elevated inflammatory markers: CRP, ESR, ferritin, d-dimer, procalcitonin 1

MIS-C vs. Kawasaki Disease

While MIS-C shares overlapping features with Kawasaki disease, key differences include 1:

• MIS-C patients are typically older (median age 8-9 years vs. <5 years for KD)
• MIS-C has higher rates of cardiac involvement and shock
• MIS-C shows more prominent gastrointestinal symptoms
• MIS-C has stronger association with elevated inflammatory markers

Laboratory and Radiologic Findings

Common Laboratory Abnormalities

• Lymphopenia occurs in 12.9% of cases 2
• Elevated white blood cell counts and neutrophil percentage are associated with severe disease 4
• Elevated procalcitonin (PCT) correlates with severity 1, 4
• Reduced bicarbonate (CO₂) levels are associated with severe disease 4

Imaging Findings

• Chest CT abnormalities are present in 63.0% of cases 2
• Ground-glass opacities, patchy shadows, and consolidations are the most prevalent findings 2
• Bilateral and multi-lobe involvement is common in severe cases 1

Management Approach

Multidisciplinary Team Requirements

Children admitted with MIS-C should be managed by 1:

• Pediatric rheumatologists
• Cardiologists
• Infectious disease specialists
• Hematologists
• Additional subspecialties as needed (neurology, nephrology, hepatology, gastroenterology)

Diagnostic Evaluation Pathway

For children under investigation for MIS-C 1:

• Tier 1 screening: CBC, CMP, ESR, CRP, SARS-CoV-2 PCR and/or serology
• Tier 2 full evaluation if CRP >25 mg/dL, ESR >40 mm/hour, or other concerning findings: add troponin T, BNP, lymphocyte count, platelet count, sodium level
• Additional studies may include chest/abdominal/CNS imaging and lumbar puncture as clinically indicated

Critical Pitfalls to Avoid

• Do not dismiss fever and respiratory symptoms as non-COVID in children, as these remain the hallmark presentations despite being less common than in adults 2
• Do not overlook isolated gastrointestinal symptoms (nausea, vomiting, diarrhea) as they can occur without respiratory symptoms and may precede typical COVID-19 manifestations 3
• Do not ignore subtle neurological changes as they may indicate progression to severe disease including acute necrotizing encephalopathy, particularly in children aged 1-1.5 years 6, 4
• Do not assume all children are mild cases - children with comorbidities and those under 3 years are at higher risk for severe disease and hospitalization 7, 4
• Recognize that co-infection with influenza is possible and can worsen outcomes 3