THE CHALLENGING AND UNPREDICTABLE SPECTRUM OF COVID-19 IN CHILDREN AND ADOLESCENTS

A novel coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in China in the end of 2019 and after less than 6 months its related disease (COVID-19) has already affected more than 6 million individuals in almost all countries worldwide.COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020, becoming one of the most challenging and concerning public health crisis faced by this generation. [1][2]][3][4] A striking feature of COVID-19 pandemic is that children and adolescents seem to be less frequently infected by SARS-CoV-2 comparing to adults.Preliminary evidence also shows that, unlike influenza or respiratory syncytial virus, children do not play a critical role in SARS-CoV-2 transmission in the community. 5Furthermore, although most infected children and adolescents are asymptomatic or present mild symptoms, recent unexpected data showing the emergence of a late-onset severe inflammatory syndrome temporally associated with SARS-CoV-2 highlights the importance of continued surveillance around the world. 6ata from laboratory-confirmed COVID-19 cases in Asia, Europe and North America, by age groups, showed that the prevalence of children and adolescents in these case series ranged from 1.0 to 1.7%.The clinical spectrum of pediatric COVID-19 is wide, ranging from asymptomatic to critically ill cases.Fever and cough were consistently the most common reported symptoms in these case series, although less frequently than in adults, followed by pharyngeal erythema, shortness of breath, rhinorrhea, nausea, abdominal pain, vomiting and diarrhea.Additional symptoms reported included myalgia, tiredness, headache, anosmia and ageusia.More recently, variable cutaneous manifestations have been described in pediatric populations with COVID-19, including erythematous rashes, urticaria, vesicular and chilblain-like lesions. 7eucopenia, lymphopenia and increased inflammatory markers (erythrocyte sedimentation rate, C-reactive protein or procalcitonin) were the most frequently reported laboratorial findings in children and adolescents with COVID-19.Although data is limited comparing to adults, lymphopenia, high levels of C-reactive protein, procalcitonin, D-dimer and creatine kinase muscle and brain (MB) biomarkers were laboratorial findings associated with more severe disease. [1][2]][3][4][5][6][7] Clinical course of COVID-19 in children and adolescents uncommonly resulted in life-threatening illness with severe outcomes.In the largest reported case series from USA, with information on hospitalization status, approximately 20% of the children and adolescents were hospitalized and 2% of them were admitted in Pediatric Intensive Care Units (PICU).Importantly, infants aged <1 year represented the age group with the highest percentage of hospitalization among COVID-19 pediatric patients.Less than 1% of children and adolescents had severe COVID-19 with acute respiratory distress syndrome or multiorgan failure. 8 recent study reporting the outcomes of children and adolescents with COVID-19 admitted to USA and Canadian PICU showed severe disease is less frequent, and early outcomes in children hospitalized are far better comparing to adults.Interestingly, among 46 children and adolescents (median age 13 years) admitted to the PICU, 40 (83%) were found to have chronic underlying health conditions, 18 (38%) of them required invasive ventilatory support and only 2 (4.2%) died.9

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