key: cord-272310-imvxrroc
authors: Nyholm, Silvia; Edner, Ann; Myrelid, Åsa; Janols, Helena; Dörenberg, Rainer; Diderholm, Barbro
title: Invasive mechanical ventilation in a former preterm infant with COVID‐19
date: 2020-07-06
journal: Acta Paediatr
DOI: 10.1111/apa.15437
sha: 
doc_id: 272310
cord_uid: imvxrroc

The consensus to date is that most infants and children only have mild COVID-19 symptoms and few require intensive care. However, there are some described exceptions and this brief report looks at a set of preterm twins born at the University Children's Hospital in Uppsala Sweden. The girl only had mild respiratory symptoms and stayed 24-hours at the paediatric ward and was then cared for at home, but the boy required intensive care and invasive ventilatory support.

The consensus to date is that most infants and children only have mild COVID-19 symptoms and few require intensive care. 1 However, there are some described exceptions [2] [3] [4] and this brief report looks at a set of preterm twins born at the University Children's Hospital in Uppsala Sweden. The girl only had mild respiratory symptoms and stayed 24 hours at the paediatric ward and was then cared for at home, but the boy required intensive care and invasive ventilatory support.

The twins, of African descent, were delivered by Caesarean section at a postmenstrual age (PMA) of 30 weeks, as the mother had pre-eclampsia and the male twin was showing intrauterine growth restriction. The boy was small for gestational age, with a birthweight of 1105 g. He was intubated and received surfactant due to infant respiratory distress syndrome and was then supported with continuous positive airway pressure therapy for another 24 hours. At PMA of 36 weeks, he had repeated severe apnoeas and needed resuscitation. Infection and oesophageal fistula were excluded, and polysomnographic registration showed an immature breathing pattern with central apnoeas. He was discharged at 38 weeks with caffeine citrate, continuous pulse oximetry and additional night-time electrocardiography monitoring. During the first week at home, he had no apnoeas, desaturations or alarms on the monitor. However, the parents said they needed to carry and comfort him constantly, while his twin sister was more satisfied.

At 39 weeks, he developed severe apnoeas and was taken by ambulance to the hospital's emergency room. He presented with irritability, tachycardia and rhonchi. After broad microbiological sampling, he was prescribed two intravenous antibiotics: Cefotaxime (50 mg/ kg three times daily) and Gentamicin (5 mg/kg daily). He was ad- The airway secretions were initially very thick. Closed endotracheal suctioning and active humidification system were applied.

Inhalation with isotonic saline started directly after intubation and was given hourly. Acetylcysteine inhalation was added from the second to third PICU day, with good effects on secretion removal. Due to previous apnoeas, caffeine citrate (10 mg/kg daily) was continued during his stay.

Chest X-rays showed variable bilateral consolidations, initially diffuse infiltrates predominantly in the right lung. (Figure 1 ). The laboratory findings showed no signs of exuberant inflammatory response. The abnormalities that were found were mild increases in procalcitonin, interleukin-6, D-dimer, ferritin and mild pancytopenia, including lymphocytopenia. The patient's serum creatinine concentration, aspartate aminotransferase, alanine aminotransferase, N-terminal prohormone of brain natriuretic peptide and triglycerides were within the normal ranges. Gas exchange improved on day six, and sedation was tapered.

The next day, he was extubated and managed with high-flow nasal cannula with low FiO 2 that was stopped after a couple of hours. No significant apnoeas were registered. After 2 days of uneventful observation, the patient was discharged home.

The take home message is that even infants can get severe COVID-19 that may require intensive care and invasive ventilatory support. Possible risk factors in this particular case may have been high and repeated viral exposure, preterm birth, immature regulation of breathing, African descent and male gender.

We want to thank our Uppsala colleagues for their help and ad- 

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