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LETTER TO THE EDITOR
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 143-144

What We Need to Consider While Combating COVID 19 in Paediatric Population is Different From Adults? Preliminary Analysis of Literature


1 Department of Paediatrics, Rajah Muthiah Medical College and Hospital, Chidambaram, Tamil Nadu, India
2 Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Puducherry, India

Date of Submission20-Apr-2020
Date of Acceptance07-Jul-2020
Date of Web Publication29-Aug-2020

Correspondence Address:
MD Dinesh Kumar. V.
Assistant Professor, Department of Anatomy, Jawaharlal Institute of Postgraduate medical education and research, Dhanvantari Nagar, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_34_20

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How to cite this article:
M. SP, Kumar. V. D. What We Need to Consider While Combating COVID 19 in Paediatric Population is Different From Adults? Preliminary Analysis of Literature. MAMC J Med Sci 2020;6:143-4

How to cite this URL:
M. SP, Kumar. V. D. What We Need to Consider While Combating COVID 19 in Paediatric Population is Different From Adults? Preliminary Analysis of Literature. MAMC J Med Sci [serial online] 2020 [cited 2020 Oct 29];6:143-4. Available from: https://www.mamcjms.in/text.asp?2020/6/2/143/293886



Sir,

Even though the rapid spread of COVID-19 contagion does not spare any age group in general, it has been observed that the manifestations of disease is not so severe when compared to elderly counterpart with not much reported deaths in children <10 years of age.[1],[2] While screening for COVID-19 among family members of a patient with pneumonia in a high-risk area, it was observed that child with laboratory proven infection did not develope red flag clinical symptoms.[3] In this letter, we shall analyse the recent literature for the existing dilemmas among health care professionals: a) what are the plausible molecular mechanisms resulting in lowered degree of pathological manifestations in children compared to adult b) what are the necessary steps required to be taken while handling neonates in the current scenario and c) what are the public health conundrums due to the overt infections in children? For precision sake we are going to avoid two insights namely, the absence of co-morbid conditions in children compared to adult and decreased exposure of pediatric population to contagion due to restricted access to external atmosphere.

Pertaining to the molecular insights, the salient theories are: I) Children have premature development of Angiotensin-Converting-Enzyme-2 (ACE2) receptor protein in the type II alveolar epithelial cells and this significantly reduces the intracellular response induced by the contagion.[4] Added to this, children have frequent respiratory tract infections due to the viruses containing RNA genome such as rhinoviruses, respiratory syncytial virus (RSV) and this could have evoked the thymus mediated cross immunity responses to COVID-19 upon invasion.[5] Furthermore, the course of the disease and severity is dependent upon the magnitude of cytokine pro-inflammatory cytokine response and it has been postulated that mortality in elderly patients infected with COVID-19 is supposedly due to cytokine storm induced multiple organ dysfunction. Fortunately, paediatric population have elevated levels of IL-10 leading to a balanced IL-10/Th1/Th2/Th17 profile and does not flare up as cytokine storm.[6] However, we should bear in mind that the viral dynamics and associated interaction with less pathogenic respiratory tract viruses varies across different parts of the world and thus we could reaffirm the generalizability of the above-mentioned hypotheses only after the pandemic settles down.

Despite having guidelines for handling of neonates in the current scenario,[7] the practicality is indeed murky because the respiratory management and even detection of positivity is not the same as in adults. In limited resource countries like us, the time to bring the entire family cluster into testing zone is significantly more when compared to countries with robust testing strategies and getting a transparent contact history is many a times difficult. Thus the feasible plan would be to test all infants associated with presence of COVID-19 positive member in the family or history of exposure to such members. The leading question would be regarding the admission of all COVID-19 positive or suspected neonates in NICU. For this, we need to decide based upon the bed surge capacity of corresponding settings and allocation of beds should be prioritised based on the presence of clinically significant presentations such as fever, short breath, vomiting of milk and cough. An alternative is to keep them in an ear-marked room near the NICU under monitoring only and transfer them to NICU when mild-flu like symptoms show off.[8] Even though the evidences regarding the pharmaceutical management in neonates are limited, we could decipher from early autopsy of adult patient that the respiratory compromise is likely due to the impairment of surfactant production from type II pneumocytes which ultimately precipitates as pulmonary hypertension.[9]Eventually, this necessitates the development of physiology based ventilation mechanisms in managing neonates who are severely affected. The other therapies including utility of immunosuppression, anti-viral regimen, Interferon-α2b nebulization, high frequency oscillation etc. warrants stronger evidences before adopting in larger scale.

Finally, we need to address the possible public health conundrums, which could possibly emanate in the current scenario. Firstly, Indian parents tend to panic more when their wards develop even minor respiratory symptoms or fever. This might lead to a surge in the number of cases in pediatric clinics, exhaust the testing facility and compromise the much needed social distancing. On the other hand, another proportion of parents might conceal the associated history of exposure fearing social stigmatization. In our practical experience, we have witnessed the first few cases of COVID-19 patients facing extreme ostracism in their neighbourhood. The next big challenge is blocking the transmission routes of viruses from recovered cases and this appears bigger considering the doubtful role of faecal transmission.[10] Once the curve of the pandemic flattens, our concern should be to decouple the plausible transmission links from asymptomatic pediatric population who could act as carriers. Till then, it is imperative to shut down places of gathering including schools and parks. Lastly, locking down for prolonged period of time might adversely affect children in terms of smartphone addiction, faulty sleep pattern, lack of physical activity, psychological changes such as depression and excessive irritability [11]. Anecdotes from newspapers reveal that children are falling prey for domestic violence in the confined homes and many such incidents tend to go unnoticed. Another important factor is provision of psychological support to the children who are diagnosed positive because on one hand, they might experience distress due to uncertainty and on other hand they could experience severe social ostracism upon recovery.

To conclude, we wish to state that, unlike previous epidemic outbreaks, much has been figured out about COVID-19 virus and its pathogenesis in a lesser time and sharing of information is much swifter in digital era. Although the collective pool of literature might not be exactly translated to our settings, we can understand the pattern of disease progression based on it and model the pandemic management ensuring appropriate resources to much needed population. We anticipate that publications regarding molecular insights and management measures wouldn’t stop in the upcoming months. Optimistically, we perceive the brunt of disease won’t fall on the pediatric population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang Z. Novel coronavirus infection in hospitalized infants under 1 year of age in China. JAMA 2020;323:1313-4.  Back to cited text no. 1
    
2.
Shen KL, Yang HY. Diagnosis and treatment of2019 novel coronavirus infection in children: A pressing issue. World J Pediatr 2020 https://doi.org/10.1007/s12519-020-00344-6.  Back to cited text no. 2
    
3.
Chan JF, Yuan S, Kok KH, To KKW, Chu H, Yang J et al. A familial cluster of pneumonia associated with the2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020 pii: S0140-6736(20)30154-9.  Back to cited text no. 3
    
4.
Kuhn JH, Li W, Choe H, Farzan M. Angiotensin‐converting enzyme 2: a functional receptor for SARS coronavirus. Cell Mol Life Sci 2004;61:2738‐43.  Back to cited text no. 4
    
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Kikkert M. Innate immune evasion by human respiratory RNA viruses. J Innate Immun 2020;12:4-20.  Back to cited text no. 5
    
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Jeljeli M, Guérin-El Khourouj V, Pédron B, Gressens P, Sibony O et al. Ontogeny of cytokine responses to PHA from birth to adulthood. Pediatr Res 2019;86:63-70  Back to cited text no. 6
    
7.
Wang J, Qi H, Bao L, Li F, Shi Y. A contingency plan for the management of the 2019 novel coronavirus outbreak in neonatal intensive care units. Lancet Child Adolesc Health 2020 doi: 10.1016/S2352-4642(20) 30040-7.  Back to cited text no. 7
    
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De Luca D. Managing neonates with respiratory failure due to SARS-CoV-2. Lancet Child Adolesc Health 2020;4:e8. doi:10.1016/S2352-4642(20)30073-0  Back to cited text no. 8
    
9.
Xu Z, Shi L, Wang Y. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020 doi: 10.1016/S2213-2600(20)30076-X  Back to cited text no. 9
    
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Tang A, Tong ZD, Wang HL, Dai YX, Li KF, Liu JN et al. Detection of novel coronavirus by RT-PCR in stool specimen from asymptomatic child, China. Emerg Infect Dis 2020;26:17.  Back to cited text no. 10
    
11.
Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020;04:04.  Back to cited text no. 11
    




 

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