Clinical characteristics & severity profile of children with COVID-19 during the second wave pandemic: An experience from tertiary care hospital in Mumbai

COVID-19 pandemic made an unprecedented and devastating social and economic impact globally1. As predicted by epidemiologists, subsequent waves of the pandemic were observed worldwide. The rising trend of paediatric cases in March-April 2021, reported by the American Academy of Paediatrics raised an alarm2. European Centre of Disease Control also reported the lower mean age group of people requiring hospitalization in the second wave3. Not only a change in age group but also an association between the presentation with non-respiratory symptoms such as gastrointestinal and skin involvement and adverse outcomes and complications were reported4,5. Hence, this study was undertaken to describe the clinical spectrum and extent of severity in children with COVID-19 infection during the second wave in a tertiary care hospital in Mumbai, India.

This was a retrospective study conducted at a dedicated COVID-19 tertiary care hospital, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India. The centre was the referral centre for Mumbai metropolitan area and received patients of all severity. A surge of cases was experienced around March 2021, with a peak in April 2021. All children aged one month-12 yr, who tested positive for COVID-19 infection by any of the methods: Rapid Antigen Test (RAT) and reverse transcriptase-polymerase chain reaction (RT-PCR) or TRUENAT conducted by the designated microbiology laboratory by the Indian Council of Medial Research (ICMR) from the throat swab or nasopharyngeal swab samples during the period from March 1 to July 31, 2021, were included in the study. Patients were graded into the severity grading of the illness and classified as multisystem inflammatory syndrome in children (MISC) according to the revised grading described by the Indian Academy of Paediatrics6. The data of the above-mentioned patients fitting into the inclusion criteria of the study were collected from the medical records and files and entered into the case record form. The compiled data were analyzed using the Statistical Package for the Social Sciences software (SPSS v 26.0, IBM Corp, Chicago, IL, USA).

The descriptive statistics was described such as frequencies and percentages for the categorical data as well as mean, median and standard deviation for the numerical data. The Chi-square test was used for comparing the frequencies of result of variable groups. The results of our experience from the first wave7 were compared with the current study. The α error was set as five per cent and β error as 20 per cent, hence giving a power to the study as 80 per cent.

During the study period, 77 children were admitted to our facility. Hospitalization rates were higher during the second wave, as reported by studies conducted worldwide8. However, lesser number of admissions as compared to our experience during the first wave7 was seen.

The demographic and clinical profile of patients is summarized in the Table. The mean age of presentation was 4.4 yr, with the youngest patient being one month old. The trend shifted towards younger demography in the second wave9. Children aged <5 years constituted the highest proportion of our patients (59.6%), similar to reports from other studies8. A similar age distribution was also noted during the first wave at our centre (65% during the first wave)7. Male predominance was noted in our study as comparable with other studies in our country10 as well as other nations8,11.

Most studies have reported the exposure to a family member as a risk factor for the contraction of infection in the paediatric group8,12. However, only 18 (23.5%) patients had a history of positive family members in our study. Community exposure in South America13 as a predominant risk factor as a result of lenient lockdown norms might explain our findings as well.

The mean duration of hospital stay of patients was 10.1 days, with two patients having fatal outcomes within 1 h of presentation. Our observation period was longer as compared to the mean stay in the paediatric patients reported by others8,14, where median stay was around five days.

Comorbidities were noted in 34 of 77 patients (44.2%). The neurological comorbidity (12/34) was the most existent subtype in the form of cerebral palsy, epilepsy, global developmental delay, autoimmune encephalitis, tuberculous meningitis, infantile tremor syndrome and structural brain malformations. No significant difference was noted in the comorbidity profile when compared with that of the first wave7. It has been observed that the presence of even one of the respiratory or non-respiratory comorbidity increases the need of hospital care as well as the need for respiratory support and mortality14.

An asymptomatic course related to COVID-19 infection was observed in 19.48 per cent (n=15) of patients, who were admitted as the parents of the patients requiring hospital care or in view of underlying high-risk comorbidity, with other studies reporting asymptomatic course in 2.5-21 per cent patients8,14. Kumar et al9 reported an increase in the proportion of adult asymptomatic patients during the second wave. Majority (41.55%) of the patients belonged to the mild category, consistent with our experience in the first wave; 20 patients (25.9%) fell under severe category.

Among the symptomatic cases, the most common symptoms reported were fever (76.6%), cough (45.5%) and rhinorrhoea (39%). Similar findings were reported by Hoang et al15. Diarrhoea was the presenting complaint in 16.8 per cent patients, similar to the 22-24 per cent prevalence reported by other studies during the second wave8,16. Poland paediatric study8 and UK paediatric study10 have correlated the symptomatology and age, where fever and cold being more common in 0-5 years as compared to >5 years. Presentation with respiratory distress was noted in our study with increased frequency as compared to the first wave (8% in the first wave and 36.6% in the present, P<0.05) with similar results in the country in the adult counterpart9. Although in our study, only one patient complained of having headache, a paediatric study17 has reported it being the most common presentation, with a prevalence of 60-74 per cent. When correlated with age, the non-respiratory symptoms were more common with less than five years of age in the study from Poland8.

The second wave was characterized by higher proportions of complications such as acute respiratory distress syndrome (ARDS) and shock9 and 25.97 per cent patients developed complications in our study. Five patients (6.4%) had clinical picture of multisystem inflammatory syndrome related to COVID-19 infection with RT-PCR-positive status. Shock was noted in 13 (16.8%) patients and three patients developed ARDS. There was no significant association found in the severity profile of the two waves of our centre, similar to other centre experiences18. A surge in MISC cases was reported by some centres in India18; however, it might reflect the referral bias of the hospital.

Chest X-ray was performed in 73 patients and 25 (34.2%) had abnormal findings, which was significant as compared to the first wave (22% in the first wave, P<0.05). Typical findings noted were bilateral involvement with diffuse, fluffy and ground-glass opacities pattern. While six (7.7%) patients required non-invasive ventilation and 13 (18.1%) required invasive mechanical ventilation. The need for non-invasive as well as invasive ventilation increased during the second wave as compared to our experience in the first wave7 (6% in the first wave vs. 24.6%, P<0.05), complying with the other reports from India9. Majority of admitted children (88.3%) were discharged without any home oxygen requirement.

A surge in mortality was observed in the second wave in India in adults9. In our study 11.6 per cent (9/77) patients had fatal outcomes, with increased frequency as compared to the first wave (3 vs. 11.6%, P<0.05). Two patients with acute history of fever and cough presented with hypoxia and succumbed to the disease within <1 h of admission. One patient with underlying Down’s syndrome and moderate acute malnutrition and one with underlying military pulmonary tuberculosis with underweight developed severe ARDS and could not be revived. One patient with severe acute malnutrition and underlying bronchiectasis developed refractory shock and multiorgan dysfunction. One patient with severe acute malnutrition also developed refractory shock and succumbed. One child with chronic liver disease post-Kasai operation for biliary atresia succumbed to acute liver failure and encephalopathy. While five patients developed MISC and two succumbed to its complications. A 3 yr old child without any underlying comorbidity presented with fever, diarrhoea and hypoxia, developed encephalopathy and cerebral infarcts and thromboembolism. The other fatal outcome was seen in nine month old child with moderate acute malnutrition who also presented with fever, diarrhoea and hypoxia.

Our study has limitation of being a retrospective design from tertiary care institute and hence may not reflect the community profile. The higher number of patients with comorbidities and complications possibly skewed the data and the results. To conclude, the second wave in the paediatric population was varied in its course, severity profile and outcomes. Despite the majority of patients having mild disease, 11.6 per cent fatality was observed and 6.4 per cent patients developed MISC with active COVID-19 infection.