key: cord-0920273-zhh7jsk1 authors: Alsharrah, Danah; Alhaddad, Fatemah; Alyaseen, Munirah; Aljamaan, Sarah; Almutairi, Nahar; Ayed, Mariam; Papenburg, Jesse; Alghounaim, Mohammad title: Clinical characteristics of pediatric SARS‐CoV‐2 infection and coronavirus disease 2019 (COVID‐19) in Kuwait date: 2020-12-01 journal: J Med Virol DOI: 10.1002/jmv.26684 sha: 719ac98d92d30e18d51d7c59ea1c10a9e6054a1b doc_id: 920273 cord_uid: zhh7jsk1 Clinical presentation of coronavirus disease‐2019 (COVID‐19) ranges from asymptomatic to severe and life‐threatening. National‐level registries found that children, generally, have less severe disease when compared with adults. However, most asymptomatically infected children will not present to hospital and may be missed. We aimed to describe the clinical characteristics in pediatric COVID‐19 patients in Kuwait, and to estimate the potential duration of viral shedding. A retrospective cohort study was performed in Jaber Alahmad Hospital (JAH) from February 29 to April 30, 2020. During the study period and as part of the public health measures, all severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐infected patients from 1 month to 18 years old, regardless of symptoms, were hospitalized at JAH, and were included. Polymerase chain reaction (PCR) negativity was defined as having two consecutive negative PCR results from a respiratory specimen. Descriptive statistics and multivariable regression analyses were performed. We found that 67.9% (95% CI, 59.4%–75.3%) of 134 SARS‐CoV‐2‐infected children were asymptomatic. Median PCR positivity was 15 days and did not vary with symptoms. Among patients who had laboratory investigations and chest imaging, symptomatic infection was associated with elevated C‐reactive protein and procalcitonin, and radiographic pneumonia. Asymptomatic SARS‐CoV‐2 infection is very common in children. Among symptomatic patients, the disease seems to be mild. Children exhibit substantial duration of viral shedding, regardless of symptoms. infected children may be inaccurate because of a lack of systematic testing and longitudinal follow-up. In the largest pediatric cohort reported in China including more than 2000 children, it was found that 4.4% patients were asymptomatic and 50.9% and 38.8% had mild and moderate disease, respectively. 7 Understanding the duration of SARS-CoV-2 viral shedding is important to control transmission and define the isolation period in the pediatric population. In one study at Wuhan Children's Hospital, researchers found a median of 15 days of viral RNA shedding in upper respiratory tract specimens. In addition, symptomatic infection, fever, pneumonia, and lymphopenia were identified as significantly with prolonged viral shedding in children with COVID-19. 8 The first pediatric COVID-19 case in Kuwait was reported on February 29, 2020. Since then, and until April 30, 2020, all confirmed pediatric SARS-CoV-2 infections older than 1 month of age and regardless of symptoms were admitted to Jaber Alahmad hospital, the designated hospital in Kuwait for patients with COVID-19. During that time, daycare centers, schools, and commercial establishments, including shopping centers, dine-in restaurants, and gyms, were closed. Cases were identified through systematic household and close contact tracing, screening of all returning travelers, and testing of all suspected COVD-19 cases. This setting created a unique opportunity to evaluate COVID-19 characteristics and duration of viral shedding measured by reverse-transcription polymerase chain reaction (RT-PCR) done on upper respiratory samples. Also, we aimed to identify predictors for symptomatic pediatric COVID-19 cases. We performed a retrospective cohort study at Jaber Alahmad Hospital (JAH) from February 29 to April 30, 2020. All PCR-confirmed pediatric SARS-CoV-2 infections from 1 month to 18 years old were included. During the study period, all patients, regardless of symptoms were evaluated on a daily basis by a pediatrician, and vitals were checked at least 3 times daily. Initially, all COVID-19 cases were admitted until two consecutive nasopharyngeal or paired nasopharyngeal/oropharyngeal samples were negative by RT-PCR. However, on April 15, 2020, hospital discharge policy was changed due to bed capacity limits; patients could be discharged to institutional quarantine, where RT-PCR testing continued. Subjects were identified using admission records from medical records and virology laboratory information system. Patients admitted for suspected COVID-19 but with negative RT-PCR results were excluded. Patient charts were reviewed to collect data on patient demographics, clinical history, significant underlying chronic comorbidities, laboratory investigations, and medical management. Daily symptoms as reported in the admission and progress notes were recorded. Disease severity categorization was based on the World Health Organization classification. 9 Results of laboratory investigations and chest radiography done at admission were collected. Data entry was reviewed by two investigators to ensure accuracy. Normal ranges for neutrophil and lymphocyte counts were based on established parameters. 10 Manufacturer's defined cutoff values were followed to determine high procalcitonin (PCT) and Creactive protein (CRP) values (Elecsys BRAHMS, Roche diagnostics, and IMMAGE immunohistochemistry system, Beckman Coulter Inc). Nasopharyngeal specimens were collected using Xpert Nasophar- Children are less likely to develop severe disease when compared with adults. 11, 12 It is estimated that less than 3% of children will develop severe or critical illness. 2, 5, 13 In our study, none developed severe or critical disease. On the other hand, 67.9% of study subjects were asymptomatic. This finding is much higher than what has previously been reported. The estimates of asymptomatic SARS-CoV-2 in children varied according to study design and setting, but ranged between 12.9% and 27.7%, according to a systematic review by de Souza et al. 5 We believe that our findings may represent a more accurate estimate for the proportion of asymptomatic SARS-CoV-2 infection in children. Subjects in our cohort were identified through active case finding, Identifying factors that are associated with symptomatic patients may help primary care and emergency room physicians to appropriately triage patients for further management. We identified that CRP, PCT, and abnormal chest x-ray, all done on admission, to be associated with symptom development. However, unlike other reports, we did not find age or white blood cell count (including neutrophil and lymphocyte counts) to be associated with symptomatic patients. 3 Due to the small number of patients with abnormal CRP, PCT, and chest radiography, as well as the absence of severe cases in out cohort, larger studies are needed to confirm our findings. Also, performing routine testing on asymptomatically infected children may not be cost effective and identification of abnormal laboratory or imaging findings may lead to unnecessary antimicrobial therapy. 15 There are limitations to this national-level retrospective cohort study. First, patient information was dependent on accuracy of data recorded in the patient chart. In addition, it was difficult to ascertain reasons behind performing certain investigations, especially in asymptomatic patients. Also, during the first 10 days of the study, samples for RT-PCR were sent-out to a reference laboratory. For that reason, these Ct values were not accessible to us. 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