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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 3  |  Page : 55-60

A portrait of COVID-19 pandemic among pediatric patients in South India: An observational study

Department of Pediatrics, Government Medical College, Manjeri, Kerala, India

Date of Submission24-Apr-2023
Date of Decision14-Jun-2023
Date of Acceptance15-Jun-2023
Date of Web Publication29-Aug-2023

Correspondence Address:
Dr. Keerthi Kumaran
Department of Pediatrics, Government Medical College, Manjeri, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pedc.pedc_14_23

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INTRODUCTION: In a report from Kerala, 7% of coronavirus disease (COVID)-positive patients were constituted by children less than 10 years old. This observational study gives a glimpse to the pattern of COVID-19 disease among the pediatric age group during the first wave of the pandemic. MATERIALS AND METHODS: This observational study was conducted in a COVID hospital in Malappuram from July 2020 to March 2021. Children under 12 years old admitted to the hospital with confirmed COVID-19 infection were included in the study. The study included main symptoms, duration of symptoms, laboratory analysis and relations with severity of disease, interventions required, and follow-up details. All these details were collected using a proforma. RESULTS: Four hundred ninety-two patients were included in the study. A total of 51.4% of these patients were asymptomatic. Only 1.8% of children had severe disease. The mean duration for which the symptoms lasted in each child was 1.9 ± 2.8 days (P = 0.00). There was a significant association between the severity of disease and presence of comorbidities, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), liver enzymes, serum ferritin, and X-ray findings (P < 0.05). Some skin lesions were noted in a group of children during the 3 months of follow-up (2%). CONCLUSIONS: During the first wave of COVID-19 pandemic, most of the children had asymptomatic disease. Severe disease was more common in children with chronic comorbidities. NLR, CRP, liver enzymes, serum ferritin, and chest X-ray findings can point toward the severity of the disease. Most of the children improved without any specific treatment. Some skin lesions such as urticaria were noted in the post-COVID period.

Keywords: Blood parameters, children, clinical features, COVID-19, follow-up, outcome

How to cite this article:
Kumaran K, Gireeshan V K, Sreeraj R, Vijayakumar M, Babu F C. A portrait of COVID-19 pandemic among pediatric patients in South India: An observational study. Pediatr Companion 2022;1:55-60

How to cite this URL:
Kumaran K, Gireeshan V K, Sreeraj R, Vijayakumar M, Babu F C. A portrait of COVID-19 pandemic among pediatric patients in South India: An observational study. Pediatr Companion [serial online] 2022 [cited 2023 Oct 5];1:55-60. Available from: http://www.pediatriccompanionkerala.in/text.asp?2022/1/3/55/384595

  Introduction Top

The world had been in the clutches of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection since December 2019. It had affected every section of our community irrespective of age, sex, race, and social status. Globally, over 700 million people were reported positive for coronavirus disease 2019 (COVID-19) infection till April 2023, with about 7 million deaths.[1] In India, the first case was reported in January 2019 in Kerala. From there, India had became the second country with most number of positive cases after the USA. All over the world, the number of COVID cases had reached above 44 million with a death toll exceeding 5 lakhs.[2] Kerala is one of the most densely populated states in South India and had reported around 6.7 million cases with about 70,000 deaths.[2] In a report prepared by the Department of Health and Family Welfare of Government of Kerala, 4.4% of COVID-positive patients constituted children less than 10 years of age.[3]

Even though we have made considerable progress in understanding the virus through numerous studies and reports since December 2019, SARS CoV-2 virus is still perilous.

As the COVID-19 pandemic advanced, with the new variant mutations, and besides the introduction of vaccines, the younger population became more in danger.

Since larger numbers of pediatric cases were reported in North Kerala during the first wave of the pandemic, researchers were able to closely monitor and thoroughly follow each case. This observational study gives a glimpse to the pattern of COVID-19 disease among the pediatric age group during the first wave of the pandemic.

  Subjects and methods Top

This observational single-arm cohort study was conducted in a COVID hospital in Malappuram district in North Kerala from July 2020 to March 2021. All children under 12 years admitted to the hospital with COVID-19 infection, confirmed either by real-time reverse transcription polymerase chain reaction (RT-PCR) or rapid antigen test (RAT), were included in the study after obtaining informed consent from their guardians.

An ethical clearance was obtained from the Institutional Ethical Committee of Government Medical College, Manjeri, Kerala, India (IEC/GMCM/44).

After getting consent from the parents, the clinical details of the children were obtained through interview with parents and from their case records. Travel history and history of contact with confirmed cases were taken from all patients.

Contact with positive cases was classified as follows:

  • Unknown contact

  • Primary contact: Contact with a confirmed COVID-19 case whose contact is unknown

  • Secondary contact: Contact with a confirmed COVID-19 case whose contact is known

  • Tertiary contact: Contact with a confirmed COVID-19 case whose contact is secondary

  • Vertical transmission: Newborns of COVID-positive mothers who tested positive on a sample taken immediately after delivery.

  • Since preventive measures by Alternative System of Medicines were popular in the locality, a history of usage of such medicines was also taken.

    All the children were classified into three categories based on their symptoms [Box 1].[4]

      Box 1: Categorization of COVID-19 Top

    Click here to view

    Blood samples were collected from each child for complete blood count, erythrocyte sedimentation rate, C-reactive protein (CRP), renal and liver function tests, serum electrolytes, serum lactate dehydrogenase (LDH), and serum ferritin. Chest X-ray and electrocardiogram were taken for only those patients with respiratory distress and cardiac dysfunction.

    According to institutional protocol for the management of COVID patients, children with respiratory distress (SpO2 below 90%) or hemodynamically unstable were given oxygen support and intravenous fluids. Inotropes were added in case of shock. Continuous positive airway pressures, noninvasive ventilation, and mechanical ventilation were given to those needed. Oseltamivir was given to children with severe disease during the initial days of disease while virology report was awaited. No other antiviral drugs were used. In addition to this, intravenous antibiotics were used to treat and prevent secondary infections. Ampicillin ± gentamycin were used as first-line antibiotics. Cefotaxim/ceftriaxone ± amikacin were used as second-line antibiotics. Those children with persistent fever and cough with no or mild respiratory distress (not requiring oxygen support) were given azithromycin. Hydroxychloroquine, which was advised by the Kerala state protocol, was not used in our institute among children.[4] Symptomatic treatments were given to children with diarrhea and vomiting. Zinc and vitamin supplements were given to all children.

    During the initial phase of the COVID pandemic, the confirmed COVID-19 patients were retested with RT-PCR on the 7th day of disease positivity. If this sample was positive, follow-up tests were done every 48 h till the sample became negative. And the children were discharged when two consecutive samples were negative 24 h apart.[5] Later, when the patient load in hospitals increased, the government revised the follow-up test policy. For asymptomatic and category A patients, the first follow-up RAT was done on the 10th day of disease positivity or 1 day after resolution of symptoms. For categories B and C, the first follow-up RAT was done on the 14th day of disease positivity or 1 day after resolution of symptoms.[6] In this study, number of days taken by each child to become negative was assessed till the policy was changed.

    After the discharge, all children were followed up through telephonic interviews at 2 weeks, 1 month, and 3 months. During the follow-up, they were enquired about any persistence of the symptoms or appearance of any new symptoms. In addition, enquiry about the development of any symptoms suggestive of multisystem inflammatory syndrome in children (MIS-C) such as persistent high-grade fever, rash, conjunctival congestion, or gastrointestinal symptoms was done.[7]

    Statistical analysis of collected data was done using SPSS version 26 (IBM SPSS Modeler Online Version). Data were described using frequency distribution, arithmetic mean, and standard deviation. Association between two variables was tested using Chi-square test.

      Results Top

    During the study period, a total of 522 children were included in the study, of which 30 patients were lost to follow-up. It was noted that most of the children had their parents as the primary contact. And, some of the parents were infected from their children [Table 1].
    Table 1: Basic details of the patients

    Click here to view

    A total of 253 children (51.4%) were asymptomatic, 63 (12.8%), 167 (33.9%), and 9 (1.9%) were in categories A, B, and C, respectively. The most common clinical feature was fever, seen in 33.1% (n = 163) of children. Other common symptoms were cough in 11.4% (n = 56), rhinitis in 9.8% (n = 48), and breathlessness in 6.7% (n = 33). Gastrointestinal manifestations such as diarrhea, vomiting, and abdominal pain were seen in 6.1% (n = 30), 7.3% (n = 36), and 2.4% (n = 12). Other presenting symptoms were sore throat, headache, seizure, altered sensorium, body ache, malaise, poor feeding, and rashes. There was only one case of MIS reported during the study period. The child presented with erythema multiforme [Figure 1].
    Figure 1: Erythema multiformae in child with MISC

    Click here to view

    The mean duration for which the symptoms lasted in each child was 1.9 ± 2.8 days. Also, a significant association was found between the duration of symptoms and the severity of disease (P = 0.00).

    Some of the children admitted were having chronic associated diseases such as congenital heart disease, cerebral palsy, seizure disorder, and childhood malignancy (n = 36). Some children were diagnosed to have other diseases during the evaluation of COVID infection such as culture-proven sepsis, pyogenic meningitis, enteric fever, and surgical condition such as appendicitis (n = 11). There was a significant association between the presence of comorbidities and severity of the disease (P < 0.001).

    A total of 24 children (4.9%) showed leucopenia (<5000 white blood cell [WBC]/µL) and 117 (23.8%) showed leucocytosis (>11000 WBC/µL). Lymphopenia was found in only 13 (2.6%) children. Transaminitis was found in 218 children (44.3%), which showed a significant association with disease severity (P = 0.00). There was a significant association between severity of the disease and neutrophil-to-lymphocyte ratio (NLR), CRP, and chest X-ray findings (P < 0.05) [Table 2].
    Table 2: Association between investigations and category of the disease

    Click here to view

    Serum ferritin level was analyzed only in 258 patients, as it is a costly investigation. The mean value of serum ferritin was 55 ± 85 µg/L. The value of ferritin showed a significant association with the severity of the disease (P < 0.012).

    Only 2.2% of the children needed oxygen support. The number of children requiring respiratory and circulatory support amounted to 0.8% (n = 4) of the study population. Oral azithromycin was used in 34.3% (n = 169) of children. Intravenous antibiotics were used in 7.3% (n = 36) cases. Hydroxychloroquine was not given to any child. Oseltamivir was used in 1.2% (n = 6) cases.

    A mean of 15 ± 5 days was taken for the RT-PCR test result to become negative in the children.

    There were three (0.6%) deaths during the study period. All these cases were children with chronic comorbidities.

    On follow-up at 2 weeks, a persistence of acute symptoms such as fever, rhinitis, and cough were reported in 2.2% of children (n = 11). Some skin lesions such as urticaria, maculopapular lesions, and desquamation of palms and soles were noted in a group of children during the 3 months of follow-up (n = 10, 2%). There were no features of MIS in any of the children. There was one case of second COVID infection in a child after 2 months of the first disease.

      Discussion Top

    In our study, describing the clinical profile and outcome of COVID-19 infection in children, most of the children were in the age group 1–5 years, which was similar to other studies.[8],[9] The male-to-female ratio was 1.03:1. Majority of the children contacted disease through primary contact with family members mostly from their parents as they were homebound due to the lockdown.[10],[11]

    As ours was a COVID hospital, the number of newborns delivered to COVID-positive mothers was high in number. This led to the inclusion of 89 newborns in our study. Among these, 48 (53.9%) became positive in the RT-PCR sample taken on the 1st day of life itself. So they were considered vertical transmission. This was considerably higher than other studies.[12],[13] So we decided to conduct another detailed study on newborns with COVID-19 infection in our institution; hence, the details are not included in this study.

    The infection in children was mainly asymptomatic, mild, or of moderate severity. Severe cases and mortality were noted in children with other chronic diseases. Overall mortality in children was found to be lesser compared with adult, as seen in various other studies.[8],[9],[10],[11],[14],[15],[16],[17] Around half of the children presented with fever, followed by respiratory symptoms and gastrointestinal symptoms.[8],[10],[15],[16],[18] Only a single case of MIS-C was reported during the study period.

    NLR, CRP, liver enzymes, serum ferritin, and chest X-ray findings showed a significant association with the severity of the disease. These markers, especially NLR can be used as a predictor of the severity of the disease. Leucopenia and lymphopenia were not associated with the severity.[19],[20],[21]

    Intensive care was needed in only less than 3% of cases.[9] This also shows that disease severity is lesser in children compared with adults.[22]

    The mean time for RT-PCR to become negative was about 2 weeks, which was similar to other studies.[9],[11]

    During the follow-up of children, we noted some skin manifestations such as urticaria, rashes, and desquamation, as reported in other studies.[23] None of the children developed MIS-C during our follow-up.


    Ms. Deepthi K. helped with the statistical analysis of the collected data.

    Authors’ contribution

    All authors contributed to conception, planning, data collection and interpretation, literature review, manuscript preparation. The final manuscript was read and approved by all authors.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship


    Conflicts of interest

    There are no conflicts of interest.

      References Top

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    Dhs.kerala.gov.in. 2021 COVID clinical management report. [cited 31 October 2021]. Available from: https://dhs.kerala.gov.in/wp-content/uploads/2020/07/Report-COVID-Clinical-Managment.pdf.  Back to cited text no. 3
    Dhs.kerala.gov.in. 2021 COVID-19 interim treatment guideline for Kerala state. [cited 31 October 2021]. Available from: https://dhs.kerala.gov.in/wp-content/uploads/2020/03/interim_24032020.pdf.  Back to cited text no. 4
    Dhs.kerala.gov.in. 2021 Revised guideline on COVID-19 testing/quarantine/isolation. [cited 31 October 2021]. Available from: https://dhs.kerala.gov.in/wp-content/uploads/2020/06/Revised-Guideline-COVID-19-Testing-Quarantine-Isolation.pdf.  Back to cited text no. 5
    Dhs.kerala.gov.in. 2021 Revised guidelines on discharge policy. [cited 31 October 2021]. Available from: https://dhs.kerala.gov.in/wp-content/uploads/2020/07/Guidelines-Revised-Discharge-Policy.pdf.  Back to cited text no. 6
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      [Figure 1]

      [Table 1], [Table 2], [Table 3]


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