Rev Peru Med Exp Salud Publica. 2020;37(4):689-93.

BRIEF REPORT
CLINICAL AND EPIDEMIOLOGICAL
CHARACTERISTICS OF CHILDREN WITH
COVID-19 IN A PEDIATRIC HOSPITAL IN PERU

Patricia Llaque-Quiroz 1,2,a,c,e, Roxana Prudencio-Gamio 1,a,b,

1
Instituto Nacional de Salud del Niño San Borja, Lima, Perú.
2
Universidad Peruana de Ciencias Aplicadas, Lima, Perú.
a
Medical doctor; b Specialist in Pediatrics; c Specialist in Pediatric Pneumology; d Specialist in Radiology, e Master of Science
in Epidemiological Research.

ABSTRACT

The aim of the study was to describe the clinical and epidemiological characteristics of children with CO-
VID-19. We analyzed the clinical records of inpatients and outpatients of the Instituto Nacional de Salud
del Niño San Borja from the period between March and May, 2020. A total of 33 patients were registered,
57.6% were males with a median age of 4.8 years (range: 2 months - 17 years). We found that 81.8% of
the children had contact with a positive COVID-19 case, 60.6% had concomitant diseases, 93.9% presen-
ted symptoms (mainly fever and cough) and the median incubation period was 7 days. The hemogram
and acute-phase reactants were normal in most cases. Chest X-ray was abnormal in 11/16 patients. All
patients received supportive treatment; 2 patients required supplemental oxygen. One patient died from
complications associated with a terminal phase brain tumor. We report the clinical and epidemiological
characteristics of children with COVID-19 during the first months of the pandemic in Peru.
Keywords: 2019 novel coronavirus; Children; SARS-CoV-2 (Source: MeSH NLM).

INTRODUCTION

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus and was declared a pandemic
on March 11, 2020. Children represent between 1 and 6% of the cases and show lower mortality
rates than adults (1). In Peru, 683,687 cases of COVID-19 have been reported, as well as 29,687
deaths due to COVID-19, of which 125 were children and adolescents (2).
Children with COVID-19 show different characteristics than adults, for example,
household contacts are identified more frequently, and most patients are asymptomatic or
Cite as: Llaque-Quiroz P, Prudencio-
Gamio R, Echevarría-Lopez S, Ccorahua- have mild symptoms (3). However, a severe onset presentation called SARS-CoV-2-associated
Paz M, Ugas‑Charcape C. Clinical multisystemic inflammatory syndrome has been reported and described only in children (4).
and epidemiological characteristics of
children with COVID-19 in a pediatric Most cases show normal counts of leukocytes, lymphocytes, and neutrophils in laboratory
hospital in Peru. Rev Peru Med Exp
Salud Publica. 2020;37(4):689-93.
tests. Elevation of acute phase reactants is not frequent in children with COVID-19 (5).
doi: https://doi.org/10.17843/ Peribronchial cuffing in chest radiography and ground-glass opacification in chest tomography
rpmesp.2020.374.6198.
are the most frequent findings (6); however, they are unspecific.
_________________________________
The ventilatory support and the use of dexamethasone in patients with respiratory failure
Correspondence: Patricia Beatriz Llaque
Quiroz; Calle Santander 171, Dpto. 405, were both useful in the management of adult patients with COVID-19 (7). There is no evidence
Miraflores. Lima, Perú; patriciallaque83@ for the use of other treatments in children.
gmail.com
There are no reports available on the most common presentations of COVID-19 in
_________________________________
Peru. Therefore, our objective is to describe the clinical and epidemiological characteristics
Received: 21/07/2020
of children treated in a national referral pediatric hospital during the first months of the
Approved: 16/09/2020
Online: 06/11/2020 pandemic.

https://doi.org/10.17843/rpmesp.2020.374.6198 689
Rev Peru Med Exp Salud Publica. 2020;37(4):689-93. Children with COVID-19 in Peru

THE STUDY
KEY MESSAGES
We conducted a retrospective descriptive study on inpa-
Motivation for the study: There are no reports on the most
tients and outpatients under 18 years of age diagnosed with common clinical presentation of COVID 19 in children in
COVID-19 and treated at Instituto Nacional del Niño San Peru.
Borja (INSNSB) from March to May 2020; children admi- Main findings: In children, initial symptoms of COVID-19
tted to intensive care were excluded. We used consecutive are similar to those of other viruses, including fever,
non-probabilistic convenience sampling. respiratory, digestive and dermal symptoms. These symptoms
are nonspecific, so epidemiological contact is important for
We reviewed the medical records of the hospitalized diagnosis in children. Disease progression in children with
patients and the chest images were examined by a pediatric comorbidities was favorable in most cases.
radiologist. We registered the laboratory test results and the Implications: Children with COVID-19 present mild
images that were obtained closest to the symptom onset or symptoms in most cases and the treatment should be mainly
up to 72 hours before or after diagnosis. symptomatic and supportive.
Outpatients were contacted prior to the study as part of
the healthcare monitoring program approved by the insti-
tution as a strategy to detect warning signs in patients with
COVID-19 treated in the triage installed since the beginning years); 63.6% (n = 21) were inpatients; 60.6% had comor-
of the pandemic. We created a follow-up system with a struc- bidities, the median number of comorbidities was 1 (range:
tured questionnaire for recording information. Patient mo- 0-5) and neurological comorbidities were the most frequent.
nitoring was made via telephone calls, which included the Only three children who were outpatients had comorbidi-
identification of epidemiological data and alarm symptoms, ties. Of the total patients, 81.8% had contact with a person
as well as education on prevention if no symptoms were de- with COVID-19 and, most of the time, the contact occurred
tected. Subsequently, telephone follow-up was done every 72 within the household. The median incubation period was
hours until the resolution of symptoms. Emergency care was seven days (interquartile range [IQR]: 4-15 days). Positive
recommended if any alarm signs were detected. molecular tests were obtained from 15/33 cases.
Children with a positive real-time polymerase chain re- Of the total number of children with COVID-19, 31/33
action (RT-PCR) test for SARS-CoV-2 or a positive serologi- patients were symptomatic. We found that 78.8% presented
cal test (IgM and IgG, or IgM) were considered COVID-19 fever, the median number of days with fever was 2 (range:
cases. Samples were obtained from serum and we used the 1-7) and 57.6% had a cough. Digestive, neurological, and
qualitative cassette format (Coretests®) as the serological test. dermatologic symptoms were less frequent (Table 1). We also
The data analysis was performed with the Stata 15.0 sta- found that 16.7% had tachypnea, 23% tachycardia, the median
tistical package. We used absolute and relative frequencies saturation was 97% (IQR: 94- 98%), and only 18.2% of patients
for qualitative variables and measures of central tendency had abnormal findings on chest examination.
and dispersion for the quantitative variables. Laboratory tests were only performed on hospitalized
This study was approved by the INSNSB Ethics Com- patients, the blood count and acute phase reactants were
mittee (code PI-437). We requested a waiver of informed normal in most patients (Table 2). We found that 3 out of 8
consent because we worked exclusively with the medical re- patients had positive IgM results for Mycoplasma pneumoniae,
cords, there was no contact with patients for study purposes. 1 out of 13 had positive blood culture for S. aureus, 2 out of
The data collected were kept anonymous and the database 3 had positive culture results for respiratory secretions, one
will be stored for three years. A code was assigned to each for Stenotrophomona maltophila and one for Pseudomona
patient, without the possibility of identification, which en- aeruginosa; 60.7% of patients received antibiotics for co-
sured confidentiality. infections.
Out of the 21 hospitalized patients, 16 had a chest X-ray.
FINDINGS Abnormal images were found in 68.8% (11/16); the most
frequent was limited lung involvement, in less than 25% (63.6%,
We evaluated 33 children with COVID-19, 57.6% were boys 7/11), of this group the most frequent finding was peribronchial
and the median age was 4.8 years (range: 2 months - 17 cuffing (Figure 1A). Only three patients had extensive

690 https://doi.org/10.17843/rpmesp.2020.374.6198
Rev Peru Med Exp Salud Publica. 2020;37(4):689-93. Llaque-Quiroz P et al.

Table 1. Clinical and epidemiological characteristics of children to central venous catheter placement. The parents of two
with COVID-19 (n = 33)
outpatients had previously administered ivermectin but did
not specify the dose. Only two patients needed supplemental
Variables n (%)
Sex
oxygen by nasal cannula.
Male 19 (57.6)
Female 14 (42.4)
Age in months* 58 (2-204) DISCUSSION
Type of patient
Inpatient 21 (63.6) The cases of COVID-19 in children that we described in this
Outpatient 12 (36.4) study correspond to the first cases treated in a national re-
Comorbidities 20 (60.6) ferral institute during the first months of the pandemic in
Neurological 8 (40) Peru. Most patients were of preschool age as described in
Congenital heart disease 4 (20) other series (8); however, infection may occur in children of
Digestive 2 (10) all ages (9). Epidemiologic contact was found in 82% of cases
Others 6 (30)
and mostly within the household; similar information has
Contact with COVID-19 patient
been reported in other studies (10), probably because children
Unknown 6 (18.2)
Household 13 (39.4)
had to stay at home during the mandatory quarantine sin-
Community 3 (9.1) ce going to school was not an option. The median incuba-
Hospital 11 (33.3) tion period was seven days, similar to the incubation period
Incubation period (days)** 7 (4-15) mentioned by Shen et al. (11).
Symptoms at presentation As reported in other series (12), fever was the most frequent
Fever 26 (78.8) symptom in children, temperature under 39 °C and lasted
Cough 19 (57.6) less than three days. Cough was the second most frequent
Diarrhea 10 (30.3)
symptom. Headache and pharyngeal pain were less frequent
Rhinorrhea 9 (27.3)
in children than in adults because these symptoms are not
Nausea or vomiting 8 (24.2)
Throat pain 6 (21.2)
expressed by young children. Tachypnea and abnormal findings
Headache 5 (15.2) on chest examination were uncommon even in hospitalized
Myalgia 3 (9.1) patients with abnormal radiological findings. Gastrointestinal
Neurological symptoms 3 (9.1) symptoms were less frequent, similar to the symptoms found
Skin lesions 2 (6.1) by Tian et al. (13), who found that diarrhea is the most common
*Median (range) gastrointestinal symptom in children, and that vomiting occurs
**Median (interquartile range)
more frequently in children than in adults; these findings
may be due to the binding of SARS-CoV-2 to angiotensin-
involvement with consolidation and involvement of more than converting enzyme 2 (ACE2) receptors on upper esophageal
75% of both lung fields (Figure 1B). None of the outpatients had epithelial cells and intestinal epithelial cells in the ileum and
chest X-rays. colon (14). During the assessment period, there were no cases of
All outpatients had mild symptomatology, and none multisystem inflammatory syndrome, which has been reported
presented complications during follow-up. During the study, in later stages of the pandemic and may be related to immune
no patients with COVID-19 were admitted to the intensive mechanisms triggered by previous exposure to the virus.
care unit. One patient died from complications of endocranial Half of the hospitalized patients had complex
hypertension due to advanced brain tumor. comorbidities and mostly were of surgical nature; however,
The treatment was mainly supportive, in case of fever or none of these patients were admitted to intensive care because
pain, paracetamol was used orally at doses of 10 to 15 mg/kg up of complications inherent to the infection. There is not enough
to every 4 hours. One patient received corticoids (intravenous evidence about the factors associated with complications of
dexamethasone, 0.3 mg/kg/dose every 12 hours) as part COVID-19 in children(15).
of the intracranial tumor management, and other received Most patients presented mild symptoms, as described by
subcutaneous enoxaparin 1 mg/kg/dose every 12 hours Dong et al. (9), who reported that 90% of children diagnosed
during his hospitalization for vena cava thrombosis secondary with COVID-19 had mild or moderate asymptomatic disease.

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Rev Peru Med Exp Salud Publica. 2020;37(4):689-93. Children with COVID-19 in Peru

Table 2. Laboratory test results for children hospitalized with COVID-19 (n = 21)

Results
Laboratory test Normal values
Median (IQR)
Leukocytes (10 /µL)
3
8,870 (6,530-14,790) 5-15.5
Neutrophiles (103/µL) 4,380 (2,420-6,652) 1.5-8.5
Lymphocytes (103/µL) 2,380 (1,400-4,040) 2-8
Hemoglobin (g/dL) 11.3 (10.4-12.7) 11.5-13.5
C-reactive protein (mg/L) 2.3 (0.75-26.65) <5
Procalcitonin (mg/dL) 0.03 (0.02-0.13) <0.5
Lactate Dehydrogenase (U/L) 650 (403-943) 240-849
Ferritin (ng/mL) 93 (55-1,327) 4-67
D-dimer (FEU/mL) 0.58 (0.27-1.37) <0.5
CPK (U/L) 55 (40-55) 7-25
IQR: interquartile range, CPK: creatine phosphokinase.

The low pediatric sensitivity to SARS-CoV-2 infection may 10.6% of cases, respectively, slightly higher percentages than
be attributed to the low expression of the cellular receptors those described by Wang et al. (12).
ECA2 and transmembrane protease, serine 2 (TMPRSS2) in Chest radiography is suggested for the initial study of
children (14). Other hypotheses include immunity training by cases with moderate and severe clinical presentation, while
the use of live vaccines and cross-media immunity with other tomography is reserved for cases with clinical deterioration (17).
The first published case series reported that most pediatric
coronavirus infections (16). In addition, the fact that children
patients had normal X-rays with few findings (10,18). However, in
have less endothelial damage may be a protective factor because
a series where pediatric radiology experts evaluated 81 X-rays of
there is a direct relationship between endothelial damage and the
children with COVID-19, they found abnormalities in 90% of
inflammatory response to SARS-CoV-2 (14).
the cases (6). In this study, we found that the percentage of patients
Blood counts were mostly within normal limits, and only two with abnormal findings (63.8%) is much higher than earlier
children were found to have lymphopenia. Most children have reports; this could be due to the fact that our institution now has
been described as having normal white blood cell counts with a radiology service dedicated to pediatric pathology. However,
neutrophilia and neutropenia found in less than 5% of cases (5). the proportion of affected patients was lower than in the series
C-reactive protein and procalcitonin increased in 13.6% and presented by Caro et al. (6).

A B

Figura 1. A. 12-year-old child with a history of intracerebral hemorrhage, parents with positive COVID-19 results. Chest x-ray shows bilateral peri-
bronchial cuffing. B. 2-year-old child. Chest x ray shows consolidation in both lungs with presence of air bronchograms.

692 https://doi.org/10.17843/rpmesp.2020.374.6198
Rev Peru Med Exp Salud Publica. 2020;37(4):689-93. Llaque-Quiroz P et al.

All children with COVID-19 received symptomatic and registry. In addition, the sample size was small because it was
complementary treatment when necessary. No pharmacolo- conducted at a single center and represents the first months of
gical treatment other than that administered was used to treat the pandemic.
the underlying diagnosis or co-infection. Currently, there is no In conclusion, in this series, the clinical presentation of
evidence of specific treatment for COVID-19 and randomized COVID-19 in children was similar to other viruses, mild
clinical trials with drugs have been developed in children over disease was found in almost all cases and the epidemiological
12 years of age. background was important for diagnosis.
Only one patient died from causes other than COVID-19
Authorship contributions: All authors worked in the conception
(oncological disease with palliative care). Lower mortality rates of the study, designed the research paper, analyzed, and interpreted
are observed in children infected with COVID-19 than in the data, wrote the article, approved the final version, and assume
adults affected by the disease (19). responsibility for all aspects of the manuscript.

Since this is a retrospective study that reviews clinical re- Funding: Autofinanciado.
cords, the main limitation was the reliability of information Conflicts of Interest: The authors have no conflict of interest to declare.

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