EPIDEMIOLOGY, INCIDENCE , pathophysiology,dignosis, investigations, vaccines, treatment, prevention

1. Covid-19 in Children
Presented by
Ali Faris Abdulbaqi
Ruqaya Hussein Ali
Hamed Mejbas Hasan
Heidi Mohammed Dhia

2. EPIDEMIOLOGY OF COVID-19
● Coronavirus disease 2019 (COVID-
19) is caused by severe acute
respiratory syndrome coronavirus 2
(SARS-CoV-2).
● The disease was first reported in
December 2019 from Wuhan,
Hubei province, China and has
since spread throughout the world.
● WHO declared a global pandemic
on March 11, 2020.

3. 3

5. COVID-19
“WHO wanted a name that
doesn’t refer to a geographical
location, animal, an individual or
a group of people.”
5
CO – Corona VI – Virus D –
Disease

6. Dec 31,2019, Clusters of cases pneumonia of
unknown origin reported to China National Health Commission
Jan 1 Seafood
market closed
Jan 5 WHO advised against
travel restrictions
Jan 11 first Coronavirus death
reported
March 24 First Death
from IRAQ
Feb 11, WHO gave name to new
Coronavirus disease: COVID-19
Jan 12 Named as 2019-nCoV Whole
genome sequence shared with WHO
Feb 24 first case in Iraq/ Najaf
March 11 WHO declare
Pandemic 12
Jan 7 Novel Coronavirus isolated

7. ● Affected Country and Territory: 167
● Confirmed cases:141 million
● Death:3 million
● Recovered:82, million
13

8. INCIDENCE OF COVID-19 IN CHILDREN
● Fewer cases of coronavirus disease 2019 (COVID-19) have been
diagnosed in children than in adults, and the majority of the pediatric
cases have been mild.
● The true incidence of SARS-CoV-2 infection in children is unknown,
due to the lack of widespread testing and the prioritization of testing
for adults and those with severe illness.
● Hospitalization rates in children are significantly lower than
hospitalization rates in adults with COVID19, which suggests that
children may have less severe illness from COVID-19 compared with
adults.

9. PATHOPHYSIOLOGY
● less is known about the pathophysiology of COVID-19.
● SARS CoV-2 infection is characterized by an initial
cytokine storm that can result in acute respiratory
distress syndrome and macrophage activation
syndrome.
● This initial phase is then followed by a period of
immune dysregulation, which is the major cause of
sepsis-related fatalities.
● differences between adult and pediatric disease are
likely the result of changes within both immune function
and the angiotensin-converting enzyme (ACE) 2
receptor, used by the virus to enter type II pneumocytes
in the lung.

10. ● In the infection phase of COVID-19, this virus uses the
enzymatic receptor of ACE2 to penetrate the host cell.
Coronavirus binding with ACE2 has been shown to lead to
a down regulation of ACE2. The decrease in ACE2 results in
a lower conversion of angiotensin to angiotensin 1–7
vasodilator.
● Thus, decrease in the stability of the pulmonary
endothelium and an aggravation of respiratory distress
● The profound lymphopenia seen in patients with COVID-19
is likely the result of T lymphocyte infection and death that
occurs as SARS CoV-2 infects these cells.

12. ● As the infection progresses, with acceleration in
viral replication and epithelial-endothelial injury, the
inflammatory response is accentuated. Interstitial
mononuclear inflammatory infiltrates and edema
followed by hyaline membrane formation occurs
leading to acute respiratory distress syndrome
(ARDS). These changes may be visible as ground
glass opacities on a CT scans

13. ● Further injury to the endothelial tissues results
in microthrombi formation and can lead to
thrombotic complications such as pulmonary
embolism, venous thrombosis, and thrombotic
arterial complications as seen in severely ill
patients.
● These complications have been seen more in
adult than in pediatric patients, although they
have been reported in the latter as well.
Secondary sepsis in these individuals further
contributes to the severety of the illness.

15. RISK FACTORS
● While all children are capable of getting the virus that causes COVID-19,
they don't become sick as often as adults. Most children have mild
symptoms or no symptoms.
● The main reported risk factors for the pediatric population to be infected
with COVID-19 were close contact with a family member with an infection
and a history of travel or residence in an endemic area.

16. But, children with underlying conditions, such as obesity, diabetes and asthma,
are at higher risk of serious illness with COVID-19. Children who have congenital
heart disease, genetic conditions or conditions affecting the nervous system
or metabolism are also at higher risk of serious illness with COVID-19.
Research suggests disproportionately higher rates of COVID-19 in Hispanic and
non-Hispanic Black children than in non-Hispanic white children. Hispanic and
non-Hispanic Black children also have had higher rates of hospitalization.

17. ROUTE OF TRANSMISSION
1. COVID-19 virus is primarily transmitted between people through
respiratory droplets and direct contact with surfaces polluted with
coronavirus.
2. Aerosol environmental generation by some medical procedures could
be the cause of transmission like endotracheal intubation, resuscitation,
and cardiopulmonary bronchoscopy, open suctioning, nebulization.
3. There have been no reports of faecal−oral transmission of the
COVID-19 virus to date in spite of the finding of the virus in stool of
patients.

18. o Children of all ages can transmit COVID-19 to others, but the rate of
transmission by young children is uncertain. Infected children shed
COVID-19 virus with nasopharyngeal viral loads comparable to or higher
than those in adult.
o Due to community mitigation measures and school closures, transmission
of SARS-CoV-2 to and among children have been reduced in the United
States during the pandemic. This may explain the low incidence in children
compared with adults.

19. An important question that remains is whether COVID-19 can be
transmitted from a pregnant woman to her fetus via vertical transmission?
Some studies focused to investigate the possibility of intrauterine transmission of
COVID-19 infection. They chose to test amniotic fluid, cord blood, and neonatal
throat swab samples at birth to ascertain the possibility of intrauterine fetal infection.
The results show that SARS-CoV-2 was negative in all of the above samples,
suggesting that no intrauterine fetal infections occurred as a result of SARS-CoV-2
infection during a late stage of pregnancy.
It is important to remember that newborn infants can acquire an infection in other
ways beyond intrauterine maternal-fetal transmission(birth canal ،post-partum breast
feeding ،inhalation of the agent through aerosols produced by coughing from the
mother..).

20. Clinical presentation of Covid-19 in children
The incubation period of SARS-CoV-2 appears to be about the same for children
as in adults, at 2- 14 days with an average of 6 days.10 symptoms of COVID-19.
While children and adults experience similar symptoms of COVID-19, children's
symptoms tend to be mild and cold-like. Most children recover within one to two
weeks. Possible symptoms can include:
❖Fever
❖Nasal congestion or runny nose
❖Cough
❖Sore throat
❖Shortness of breath or difficulty breathing
❖Fatigue

21. ❖Headache
❖Muscle aches
❖Nausea or vomiting
❖Diarrhea
❖Poor feeding or poor appetite
❖ New loss of taste or smell Belly pain
❖ Pink eye (conjunctivitis)
❖Children infected with SARS-CoV-2 may have many of these non-specific
symptoms, may only have a few (such as only upper respiratory symptoms or only
gastrointestinal symptoms), or may be asymptomatic. The most common symptoms
in children are cough and/or fever.

22. WHY DO CHILDREN REACT DIFFERENTLY TO
COVID-19?
The answer isn't clear yet. Some experts suggest that children might not be as
severely affected by COVID-19 because there are other coronaviruses that spread
in the community and cause diseases such as the common cold. Since children
often get colds, their immune systems might be primed to provide them with
some protection against COVID-19.
It's also possible that children's immune systems interact with the virus differently
than do adults' immune systems (as mentioned before in pathophysiology ). Some
adults are getting sick because their immune systems seem to overreact to the
virus, causing more damage to their bodies. This may be less likely to happen in
children.

23. Although rare, children under age 1 appear to be at higher risk of severe illness
with COVID-19 than older children. This is likely due to their immature immune
systems and smaller airways, which make them more likely to develop breathing
issues with respiratory virus infections.
Research suggests that only about 2% to 5% of infants born to women with
COVID-19 near the time of delivery test positive for the virus in the days after
birth. However, if mother is severely ill with COVID-19, she might need to be
temporarily separated from her newborn.

24. Diagnostic methods
● Preferred diagnostic test is Reverse transcriptase Polymerase chain
reaction(RT PCR) for SARS CoV2 RNAdc.
● Preferred sample for children not receiving mechanical ventilation are upper
respiratory tract sample (nasopharyngeal and oropharyngeal swab) these
should be transported in viral transport media on(VTM) ice
● In mechanically ventilated children bronchoalveolar lavage or endotracheal
aspirate would be the preferred specimen These have to be mixed with the
viral transport medium and transported on ice .
● Sputum induction should be avoided in view of risk of aerosol generation

25. Laboratory studies
Although a consistent pattern of characteristic laboratory findings has not yet been
identified in children with confirmed COVID-19, the following abnormalities have been
observed:
● Lymphopenia
● Increased levels of liver and muscle enzymes and lactate dehydrogenase
● Increased myoglobin and creatine kinase iso enzyme levels
● Elevated C-reactive protein (CRP) level
● Elevated erythrocyte sedimentation rate
● Increased procalcitonin level
● Elevated D-dimer
● Elevated levels of inflammatory factors such as interleukin (IL)-6, IL-4, IL-10, and
tumor necrosis factor (TNF)-α

26. Blood SARS -CoV 2 antibody detection:
● Serum sARS CoV 2 specific antibodies IgM and IgG test positive for two
consecutive times is helpful for diagnosis However,negative antibody tests
cannot exclude infection at the early stage of disease onset .
● Non specific reactions must be ruled out for positive IgM antibody detection
● The diagnostic value of IgM and IgG detection needs further evaluation,
because it takes a certain period for the body to produce serum specific
antibodies and reach the detection threshold after virus infection and the
kinetic features of serum specific antibody production after the virus
infection are still unclear
● Antibody test can be used for retrospective auxiliary diagnosis and sero
epidemiological surveys

27. ● Alterations in leukocyte indices appear to be mostly inconsistent in
children,unlike the case of adults with COVID 19 Therefore, leukocyte
indices in children do not appear to be reliable markers of disease severity
Instead, serially monitor C reactive protein (crp)procalcitonintest (pct) and
lactatedehydrogenase(LDH) levels, to monitor the course of the disease in
children hospitalized with COVID 19.

28. ● Elevated Creatine kinase MB (CK MB) levels in children with mildCOVID
19 suggest the possibility of cardiac injury, highlighting the importanceof
monitoring cardiac biomarkers in hospitalized patients and the need for
further investigation.
● Rapid serology kits may not be positive during first 7–10 days of infection
and stay positive for several weeks following infection

29. Imaging studies
● Imaging is not indicated for pediatric patients presenting with mild clinical
symptoms unless the patient has risk factors for disease progression or develops
worsening clinical symptoms.
● Sequential chest radiograph examinations, ordered on an as-needed clinical
basis, are indicated for pediatric patients with COVID-19 to assess response to
therapy, evaluate clinical deterioration, or assess the positioning of life support
devices
● Post-recovery follow-up imaging is not recommended for asymptomatic pediatric
patients with a mild COVID-19 disease course; however, it may be considered in
asymptomatic individuals with an initial moderate-to-severe disease course or
symptomatic individuals regardless of initial disease severity depending on the
level of clinical concern for long-term lung injury.

30. Digital X ray photography
● x-ray photography is not recommended as the first choice,because it is easy
to missed diagnosis Infected pediatric patients commonly have no abnormal
X ray imaging results at the early stage of disease onset Only those severe
cases or those at the progression stage show white lung pattern X ray
photography.
● Common chest radiograph findings in children with COVID-19 pneumonia
include bilaterally distributed peripheral and subpleural ground-glass
opacities and consolidation.

31. A and B a fourteen-year-old boy with fever and cough.
A. Chest x-ray shows diffuse areas of peri-bronchial thickening. There is
slight predominance in the parahiliarregions.
B. Magnified right lower lobe shows dense cuff surrounding an aerated
bronchus.
C. corresponds to a ten-year-old girl with patchy bilateral ground-glass
opacities (arrows).

32. CT scanning
• Chest CT Scan: According to recent evidences the CT scan
findings of COVID-19 pneumonia manifested as multifocal
unilateral or bilateral ground glass opacity (GGO) to mixed GGO
and consolidation mostly peripheral located. GGO are usually
seen in the early days and progress to the consolidation in the
following days. Lymphadenopathy is usually not seen and pleural
effusion is rare and mild.
• In general, normal chests CT scan maybe helpful in rule out of
COVID-19.
Indications of chest CT scan are:
A) Bilateral lung involvement on CXR.
B) ICU admission.
C) In a patient who has not responded to primary treatment and is
developing worse

33. CT scanning
• Chest CT Scan: According to recent evidences the CT scan findings of COVID-19
pneumonia manifested as multifocal unilateral or bilateral ground glass opacity
(GGO) to mixed GGO and consolidation mostly peripheral located. GGO are usually
seen in the early days and progress to the consolidation in the following days.
Lymphadenopathy is usually not seen and pleural effusion is rare and mild.
• In general, normal chests CT scan maybe helpful in rule out of COVID-19.

34. TREATMENT
1 Supportive
– Maintenance fluid (oral and/ or intravenous) and calorie intake.
– Antipyretics: paracetamol.
– Antibiotics (broad-spectrum) when secondary bacterial infection occurs.
– Oxygen supplementation in moderate to severe cases is aimed to prevent ARDS,
organ failure, and secondary infection.
– Nasal high-flow oxygen therapy, and non-invasive or
invasive mechanical
ventilation should be undertaken when necessary.
2 Steroids
Steroid therapy is not indicated in majority of pediatric COVID-19 patients as they usually
get well without severe complications

35. 3- Anticoagulant
Malignancy, obesity, and chronic heart diseases may be significant risk factors for
VTE.
Enoxaparin prophylaxis is advised in children and adolescent confirmed COVID-19
cases.
4- Antiviral medications
The safety and effectivity of antivirals for treating COVID-19 have not been approved
yet. Examples of possible antivirals used in COVID-19 patients are lopinavir/ritonavir
and favipiravir and remdesivir

36. 5- Convalescent plasma
• It has no official approval from (WHO).
• However, the administration of convalescent plasma in the
early stage of severe COVID-19 disease has shown good
recovery results.

37. Prevention
1. Clean your hands often. Use soap and water, or an
alcohol-based hand rub.
2. Maintain a safe distance from anyone who is coughing
or sneezing.
3. Wear a mask when physical distancing is not possible.
4. Don’t touch your eyes, nose or mouth.
5. Cover your nose and mouth with your bent elbow or a
tissue when you cough or sneeze.
6. Stay home if you feel unwell.
7. If you have a fever, cough and difficulty breathing, seek
medical attention.
8. Calling in advance allows your healthcare provider to
quickly direct you to the right health facility. This
protects you, and prevents the spread of viruses and
other infections.
9. Wear a mask when going outside
10. Follow the advice provided by your local health
authority.
11. Get vaccinated.

38. Vaccines
The best COVID-19 vaccine is the first one that is available to
you. Do not wait for a specific brand. All currently authorized
and recommended COVID-19 vaccines:
• are safe,
• are effective, and
• reduce your risk of severe illness.

39. Common side effects
• A severe or persistent headache
• Blurred vision
• Chest pain
• Shortness of breath
• Swollen legs
• Persistent abdominal pain
• Unusual skin bruising
• Pinpoint spots (not including the injection site)

40. AstraZeneca Vaccine
Type: vector vaccine
Protection: 76% efficacy, 100% against severe manifestation
and death
Possible side effects:
Thrombotic events were reported rarely (a reaction similar to
heparin induced thrombocytopenia)

41. Senopharm Vaccine
Type: inactivated virus
Protection: 79% efficacy, 100% against
severe disease and death
Side effects are milder

42. Pfizer/BioNTech's Vaccine
Type: mRNA vaccine
Pretection: 95% efficacy, 100% against severe
disease and death

43. Why a vaccine for children will take longer?
● Kids weren’t involved in the original adult clinical trials because the data
tells us that severe illness from COVID-19 tends to happen to adults
(especially in older adults). We’re not seeing the same sort of response
or sickness in children.
● One of the reasons for focusing on an adult version first is because when
children are involved in clinical trials, there is oftentimes more layers of
protection to go through. For instance, the child and both parents typically
have to agree to participate in the trial or study.
● Immune systems in kids can vary greatly depending on age.

44. Thank you
Any questions?