CLINICAL FEATURES AND SHORT-TERM OUTCOME OF COVID-19 IN PEDIATRIC PATIENTS IN A TERTIARY CARE HOSPITAL OF CENTRAL INDIA: A CROSS-SECTIONAL STUDY

Objectives: To fill the knowledge gap and make a clinical profile (frequency, clinical features and outcome) of COVID-19 paediatric patients attending the tertiary care hospital of central India. Methodology: This cross-sectional study was carried out in Department of Paediatrics, R.D Gardi Medical College, Ujjain, M.P among 88 age group of 0-18 years admitted consented COVID-19 positive pediatric patients over a period of one year (March 2021 to April 2022). Results: Fever was the most common (76%) complaint, followed by fatigue/ malaise (52%), dry cough and runny nose (45%). Fever stayed for the longest duration (2.80±2.30 days), followed by loss of smell (1.97±2.43 days). Skin rashes stayed for the least duration (0.09±0.39 days). Stunting was observed in 28% participants. Hospital acquired pneumonia was seen in many (26%), along with liver dysfunction in 19%, ARDS in 18%, meningitis/ encephalitis in 16%, MIS-C in 8% and septic shock in 7%. Most of the study participants (49%) had received Azithromycin; while Ivermectin was given to very few participants (16%). Mean duration of stay in hospital was observed to be 9.01±7.95 days. COVID-19 severely hampered the vulnerable section of the society, i.e., the children. Conclusion: The prevalence was found to be more in females, and increased with advancing age. Overcrowding and under nutrition favoured its spread. Children presented with variable complications, as well.


INTRODUCTION
Despite having widespread knowledge about the natural course of the disease, infectious diseases are still one of the leading causes of morbidity and mortality worldwide.The emergence and re-emergence of various pathogens have created new challenges for mankind.COVID-19 emerged as a global health crisis, first causing an epidemic in China and then a pandemic that affected the entire world [1].As the pandemic continued, numerous reports describing the clinical presentation and hospital course of children with confirmed COVID-19 emerged.In the early stages of the pandemic, the proportion of confirmed cases among the pediatric age group was relatively small, and it was believed that children were rarely affected by COVID-19 [2][3][4].The number of affected children increased dramatically in the later stages of the COVID-19 pandemic.Subsequent researches showed that although children and adolescents were susceptible to COVID-19 infection, a large percentage of children were either asymptomatic or pre-symptomatic, and therefore, the true incidence of infection was understated due to the low rate of testing in children [5].According to national and international statistics, only 2-3% of sick children required hospitalization.Deaths in children caused by COVID-19 account for 2% of all deaths [6,7].Fever was the most common sign at presentation, followed by cough, rhinorrhea, and a sore throat.Other common symptoms were diarrhea, headache, myalgia, rashes, and, in some cases, anosmia or ageusia too [8].Although most children with non-severe symptoms of COVID-19 recover within 7-14 days of disease onset, clinical deterioration may occur later, so prompt urgent re-evaluation is needed [9,10].Despite the low prevalence of COVID-19 in children, guaranteeing their protection against the virus is nevertheless a growing concern because the pediatric population constitutes a sizeable vulnerable group.There are cases of multi-system inflammatory syndrome in children (MIS-C) that appear to be associated with COVID-19 manifesting with high fever, rash, conjunctivitis, and gastrointestinal symptoms with multiple-organ failure [7].Being a novel disease, in India, there is a paucity of information and a lack of research on disease outcomes in the pediatric age group.Therefore, this study is an effort to fill the knowledge gap and make a clinical profile (frequency, clinical features, and outcome) of COVID-19 pediatric patients (0-18 years) attending the tertiary care hospital in central India.

METHODS
The present cross-sectional study was carried out in the Department of Pediatrics, C.R. Gardi Hospital, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, after approval by the Institutional Ethics Committee, among 88 consented COVID-19 positive (pharyngeal swab positive for viral RNA) pediatric patients (0-18 years) who were admitted here over a period of 1 year (March 2021 to April 2022).

Sample size calculation
The population size (for the finite population correction factor or fpc) (N) was taken as 1,000,000.Hypothesized % frequency of outcome factor in population (p) was taken as 5%±5.Confidence limit as % of 100 (absolute±%) (d) was 5%.The design effect (for cluster surveys, DEFF) was considered to be 1.
A detailed history and presentation of complaints were recorded.A general and systemic examination was done following all the necessary SOPs (standard operating procedures) advised while handling COVID-19 cases.

Statistical method
Data were collected using pre-designed pro forma and later transformed into an electronic data case using Microsoft Excel R. Results were expressed as the means and standard deviation or as numbers and percentages.The data were analyzed using Stata 12 software.

OBSERVATION AND RESULTS
Table 1 depicts the distribution of study subjects on the basis of various sociodemographic characteristics.The majority of the participants (67%) were >10 years old, while 22% were between 5 and 10 years old, and the remaining 11% were <5 years old.The mean age was 11.63±5.10years.
A preponderance of girls (60%) was observed.Most of the participants belonged to nuclear families (70%) and resided in urban areas (82%).
The mean mid-upper arm circumference was measured at 13.40±0.82.
The comorbidities assessed in the study were hypertension, chronic cardiac disease, chronic pulmonary disease, asthma, tuberculosis, stroke, chronic neurological disease, rheumatologic illness, immunosuppressive medication, past or family history of Kawasaki disease, diabetes mellitus, obesity, chronic kidney disease, chronic liver disease, HIV infection, malignancy, chronic Hepatitis B and C infection, autoimmune disease, congenital or acquired immunodeficiency, and hematological disorder.However, no comorbidities were found in the study population.The complications developed during the hospital stay were also studied (Table 4).Hospital-acquired pneumonia was seen in many (26%), along with liver dysfunction in 19%, ARDS in 18%, meningitis/encephalitis in 16%, MIS-C in 8%, and septic shock in 7%.The treatment received by the study participants is depicted in Table 5.Most of the study participants (49%) had received azithromycin, while ivermectin was given to very few participants (16%).The mean duration of stay in the hospital was observed to be 9.01±7.95days.

CONCLUSION
COVID-19 severely hampered the vulnerable section of society, i.e., the children, and hence, this study aimed to identify the various clinical features and outcomes of COVID-19 in children.The prevalence was found to be higher in females and increased with advancing age.Overcrowding and undernutrition favored its spread.Children presented with variable complications as well.The study was conducted on a limited number of patients.National multicentric trials can throw better light on the different kinds of presentation of COVID-19 in the pediatric age group.

Fig. 2 :Fig. 1 :
Fig. 1: Distribution of study subjects as per the BCG and MMR vaccine status

Table 3 : Distribution of study subjects on the basis of nutritional status (n=88)Table 6 : Distribution of study subjects on the basis of mean age, anthropometric measurements, and duration of hospital stay Agrawal et al. their
[16]y.Dong et al.[11]reported a higher proportion among the 6-10-year-old age group.Cui et al.[16]in a systematic review reported the highest number of COVID-19 cases (38%) above 10 years of age.