Meeting Reviews

Session IV: COVID in the Pediatric Population

By Pablo Motta, MD

Session IV: “COVID in the Pediatric Population” was moderated by Gregory J. Latham, MD and Lindsey Loveland Baptist, MD. It included two outstanding speakers, Todd J. Kilbaugh, MD and Jane W. Newburger, MD, MPH.

Dr. Kilbaugh is an Associate Professor of Anesthesia, Critical Care, and Pediatrics
at the Children’s Hospital of Philadelphia. He is the Director of the CHOP ECMO Center and the Anesthesia and Critical Care Mitochondrial Unit. Dr. Kilbaugh’s presentation was
“How and Why COVID is Different in the Pediatric Population”. 

His goals for the talk were to help attendees understand COVID-19 pathophysiology and therapeutic recommendations in pediatric critical care including the role of extracorporeal support. He also reviewed the resource allocation in the intensive care unit during the COVID-19 pandemic. Dr. Kilbaugh’s presentation started by reviewing the epidemiology of COVID-19 in children, in particular, those admitted to the ICU. His initial conclusion was that “Deaths or other severe outcomes are rare in children with SARS-CoV-2 - but do occur”.

Next, he described the proposed hypotheses for the age-related difference in the severity of COVID-19. On one of his slides, Dr. Kilbaugh presented a very descriptive illustration of the three phases of the disease - stage I (early infection), stage II (pulmonary phase), and stage III (hyper inflammation phase). For each one of the phases, there are different treatment alternatives. The goal of stage I is to inhibit viral replication with antivirals (e.g., remdesivir), convalescent plasma, and monoclonal antibodies. Stage II is mostly supportive care and stage III is crucial to modulate immune response with steroids or immunosuppressants (e.g., tocilizumab or baricitinib).

Besides the medical implications of COVID-19, Dr. Kilbaugh analyzed the other impacts of the disease on children including lost education, mental health, obesity, reduced physical activity, delays in seeking routine care including dental care and vaccinations, abuse, and reduced financial security. To conclude, Dr. Kilbaugh gave a personal reflection of COVID-19 through a story of one of his patients. His final message was clear, “In 2020 critical care saves lives”.

Dr. Newburger, who is the Associate Chief for Academic Affairs in the Department of Cardiology, Commonwealth Professor of Pediatrics at Harvard Medical School, presented “The Arthur Keats Lecture: Pediatric Multi-System Inflammatory Syndrome in Children: Focus on Cardiac Manifestations”. Dr. Newburger is part of Boston Children’s MIS-C team which has been very productive in leading the research in this new field. She is also involved in the MUSIC study (Long-Term Outcomes after the Multisystem Inflammatory Syndrome In Children) and the CDC overcoming COVID-19 tracking MIS-C tool.1,2   

Her presentation was didactic and full of graphics with up-to-date COVID-19 information. Dr. Newburger’s presentation started with a review of the epidemiology of Multi-System Inflammatory Syndrome (MIS-C). She remarked that COVID-19 is less common and less lethal in the pediatric population. The definition of MIS-C includes several criteria such as age < 21 years, fever ≥ 38.5°C, evidence of inflammation, multisystem (≥2 organ system involvement), and previous COVID-19 infection (2-6 weeks prior).

Similarly to Kawasaki disease, MIS-C predominates in males (58%). Likewise in the adult population, minorities (e.g., Black and Latino) and obese patients have a higher incidence of MIS-C. Through instructive illustrations, Dr. Newburger went over the pathophysiology and clinical manifestations of MIS-C. In addition to cardiovascular manifestations - dermatologic, gastrointestinal, and neurologic symptoms are common. She highlighted the echocardiographic findings of MIS-C which include largely left ventricular dysfunction (systolic and diastolic); coronary aneurysms are rare in contrast to Kawasaki disease. Diastolic dysfunction presents more common than systolic dysfunction and has a delayed resolution. Cardiac MRI can be useful in obese patients with poor echocardiographic windows to detect myocardial edema, scar, and/or coronary involvement.

Finally, Dr. Newburger reviewed the management of MIS-C which included immunomodulation, antithrombotic therapy, and symptomatic treatment. The follow up of these patients includes a cardiac MRI for function surveillance and coronary involvement. She concluded the talk by describing a few unknowns on this disease including long-term cardiac outcomes and potential predictive laboratory risk factors.

1. https://www.nhlbi.nih.gov/news/2021/longitudinal-study-follows-multisystem-inflammatory-syndrome-children-mis-c
2. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/infographic-mis-c.html