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    1 Comment for this article
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    Outcomes for Children with COVID-19 in Pediatric ICUs
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    On 17 July 2020, White House Press Secretary Kayleigh McEnany cited this JAMA Pediatrics article in support of the US administration's plans to reopen primary and high schools in the Fall of 2020. The research is said to have found that coronavirus is “far less” severe in children than in adults, and concluded kids are at “far greater risk” from influenza.  

    The important and extensive Original Investigation, dated 11 May 2020, on critical care by a team of experts from leading US medical schools and hospitals  investigated the characteristics and outcomes of 48 children, of whom 40 (or
    83%) had preexisting underlying medical conditions, with 11 (or 23%) having failure in 2 or more organ systems, and were also infected with COVID-19, in pediatric intensive care units (PICUs).

    It was concluded that "that severe illness is less frequent, and early hospital outcomes in children are better than in adults."

    This is a strong conclusion that relies on a small number of children, as compared with the significantly larger population of adults, with and without preexisting medical conditions, in ICUs because of COVID-19.

    An even stronger observation was based on admissions to PICUs between 14 March 2020 and 3 April 2020, it was found that "the overall burden of COVID-19 infection in children remains relatively low compared with seasonal influenza. ...  children continue to face a far greater risk of critical illness from influenza than from COVID-19".

    This conclusion was based on influenza-related deaths in children 14 years or younger during the entire 2019-2020 influenza season, as compared with COVID-cases for a period of just 3 weeks.

    As the cross-sectional study is now more than two months old, a follow-up clinical experimental study is essential, and should consider the following factors:

    (1) a cross-sectional comparison of children in PICUs with adults in ICUs, based on larger and more extensive samples of both children and adults that would now be available;

    (2) separating children and adult patients with and without preexisting conditions, based on 1, 2 or more failing organ systems;

    (3) comparing deaths from influenza and COVID-19 for a longer duration to make comparisons more meaningful and convincing;

    (4) extending the follow-up period for children and adults from 7 days to 3 weeks as a guard against possible reinfection from COVID-19;

    (5) subject to ethical considerations, analyzing the effectiveness on children and adults of pharmacotherapies that are intended to modulate infection from COVID-19, including hydroxychloroquine, azithromycin, remdesivir, and tocilizumab, none of which has yet been found to be safe and effective against COVID-19;

    (6) comparing countries, states, regions, and provinces where opening up the economy, especially schools, to check for differences in children admitted to PICUs.

    Medical researchers cannot control the variety of (mis-) interpretations that arise for a number of reasons, many of them political, but emphasizing the caveats associated with experimental clinical trials would highlight the implications for public health considerations of COVID-19 patients, both young and old.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    Caring for the Critically Ill Patient
    May 11, 2020

    Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units

    Author Affiliations
    • 1Texas Children’s Hospital, Baylor College of Medicine, Houston
    • 2Children’s Healthcare of Atlanta, Atlanta, Georgia
    • 3Ann and Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    • 4Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
    • 5Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
    • 6Baystate Children’s Hospital, UMass Medical School Baystate Campus, Springfield, Massachusetts
    • 7Children’s Hospital of Michigan, Wayne State University, Detroit
    • 8Bristol-Myers Squibb Hospital, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
    • 9NewYork-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York
    • 10Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
    • 11Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia
    • 12Seattle Children’s Hospital, University of Washington, Seattle
    • 13Children’s Memorial Hermann Hospital, University of Texas, Houston
    • 14Children’s National Medical Center, George Washington School of Medicine, Washington, DC
    • 15Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
    JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948
    Key Points

    Question  What has been the early experience of coronavirus disease 2019 (COVID-19) in pediatric intensive care units (PICUs)?

    Findings  In this cross-sectional study of 46 North American PICUs, between March 14 and April 3, 2020, 48 children were admitted to 14 PICUs in the US and none in Canada. A total of 40 children (83%) had preexisting underlying medical conditions, 35 (73%) presented with respiratory symptoms, and 18 (38%) required invasive ventilation, and the hospital mortality rate was 4.2%.

    Meaning  This early study shows that COVID-19 can result in a significant disease burden in children but confirms that severe illness is less frequent, and early hospital outcomes in children are better than in adults.

    Abstract

    Importance  The recent and ongoing coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented toll on adults critically ill with COVID-19 infection. While there is evidence that the burden of COVID-19 infection in hospitalized children is lesser than in their adult counterparts, to date, there are only limited reports describing COVID-19 in pediatric intensive care units (PICUs).

    Objective  To provide an early description and characterization of COVID-19 infection in North American PICUs, focusing on mode of presentation, presence of comorbidities, severity of disease, therapeutic interventions, clinical trajectory, and early outcomes.

    Design, Setting, and Participants  This cross-sectional study included children positive for COVID-19 admitted to 46 North American PICUs between March 14 and April 3, 2020. with follow-up to April 10, 2020.

    Main Outcomes and Measures  Prehospital characteristics, clinical trajectory, and hospital outcomes of children admitted to PICUs with confirmed COVID-19 infection.

    Results  Of the 48 children with COVID-19 admitted to participating PICUs, 25 (52%) were male, and the median (range) age was 13 (4.2-16.6) years. Forty patients (83%) had significant preexisting comorbidities; 35 (73%) presented with respiratory symptoms and 18 (38%) required invasive ventilation. Eleven patients (23%) had failure of 2 or more organ systems. Extracorporeal membrane oxygenation was required for 1 patient (2%). Targeted therapies were used in 28 patients (61%), with hydroxychloroquine being the most commonly used agent either alone (11 patients) or in combination (10 patients). At the completion of the follow-up period, 2 patients (4%) had died and 15 (31%) were still hospitalized, with 3 still requiring ventilatory support and 1 receiving extracorporeal membrane oxygenation. The median (range) PICU and hospital lengths of stay for those who had been discharged were 5 (3-9) days and 7 (4-13) days, respectively.

    Conclusions and Relevance  This early report describes the burden of COVID-19 infection in North American PICUs and confirms that severe illness in children is significant but far less frequent than in adults. Prehospital comorbidities appear to be an important factor in children. These preliminary observations provide an important platform for larger and more extensive studies of children with COVID-19 infection.

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