See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/348327357

Comorbidity and COVID-19 in Children -A Single Center Experience

Article · January 2021

CITATIONS READS

0 5

14 authors, including:

Attia Bari Iqbal Bano

The Children's Hospital and the Institute of Child Health The Children's Hospital and the Institute of Child Health
60 PUBLICATIONS   125 CITATIONS    39 PUBLICATIONS   58 CITATIONS   

SEE PROFILE SEE PROFILE

Masood Sadiq
The Children's Hospital and the Institute of Child Health
51 PUBLICATIONS   598 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

CONGENITAL HEART DEFECT View project

Reflective abilities of dental students View project

All content following this page was uploaded by Attia Bari on 08 January 2021.

The user has requested enhancement of the downloaded file.

Vol 44 (1)
(3) March,
(4) 2020
December
September,, 2020

SPECIAL SUPPLEMENT
ORIGINAL ARTICLE
Comorbidity and COVID-19 in Children - A Single Center
Experience
AIMEN CH, ATTIA BARI, JUNAID RASHID, Yasin Alvi, Farrah Naz, Nasir Rana, Iqbal Bano,
Abid Qureshi, Khalida Aamir, Naureen Akhtar, Shazia Maqbool, Nisar Ahmad,
Muhammad Saleem, Masood Sadiq
------------------------------------------------------------------------------
Pak Pediatr J 2020; 44(4):306-13
ABSTRACT
Objectives: To describe the epidemiological characteristics, clinical
presentation, severity of the disease, and early outcomes of children
with COVID-19 in Pakistan with special reference to underlying
comorbid conditions.
Study Design: Descriptive cross-sectional study.
Correspondence to:
Place and Duration of Study: The Children’s Hospital and The
Masood Sadiq, Institute of Child Health, Lahore, from March 15 to July 31, 2020.
Professor of Pediatric Cardiology Material and Methods: We analyzed data on all laboratory-confirmed
and Dean, The Children’s Hospital cases of severe acute respiratory syndrome coronavirus 2 (SARC-
and the Institute of Child Health,
Ferozepur Road, Lahore 54000.
COV- 2) infection in children admitted to a single tertiary care center
Pakistan. including patient characteristics, clinical course and hospital outcomes
with special reference to underlying comorbidity.
Results: Of 42 symptomatic children, 19 (45%) had a pre-existing
E-mail: comorbidity, the most common of which was chronic kidney disease
drmasoodsadiq@hotmail.com
(7/19- 37%). The median age was 7.75 years (IQR: 1.3–11.2) with a
slight female preponderance (55%). Fever (79%), respiratory
Received 26th November 2020 symptoms (52%), and gastrointestinal symptoms (14%) were the most
Accepted for publication common symptoms. No direct or indirect contact with COVID-19
30th November 2020 positive person was identified in 12 patients (29%). Patients with pre-
existing comorbidity required mechanical ventilation and prolonged
intensive care monitoring than those without. There were three
fatalities in the groups of 42 (7%) patients, and underlying comorbid
conditions were significantly associated with a fatal outcome
(p=0.032).
Conclusion: COVID-19 in children is generally mild with good
outcome. Chronic kidney disease was the commonest co-morbidity
and the presence of an underlying co-morbid condition is a risk factor
for prolonged hospital stay and a poor outcome.
Key Words: COVID-19, Co-morbidity, Children.
INTRODUCTION CoV-2), are disproportionately represented in
Pakistan as 10.3% (29298/284660) of the total
Children and adolescents with coronavirus
confirmed cases of COVID-19 are in persons
disease 2019 (COVID-19), caused by severe
aged <20 years.1 However, COVID-19 is a
acute respiratory syndrome coronavirus 2 (SARS-

www.pakpedsjournal.org.pk
 Comorbidity and COVID-19 in Children - A Single Center Experience
relatively mild disease in children, with a low
mortality.2 A new inflammatory syndrome, known
as multisystem inflammatory syndrome in children
(MIS-C), has also been reported to be temporally
associated with COVID-19 infection.3,4 The
disease pattern in children is less severe than that
in adults.5,6 In a systematic review of 7480
children aged <18 years, information regarding
the symptoms and severity of the disease was
available for 1475 children.5Of these, 85% of
cases were symptomatic, 42% were mild, 39%
were moderate, 2% were severe, 0.7% were
critical, and the total mortality rate was 0.08%.
Furthermore, a high proportion of newborns were
severely ill (12%), and dyspnea was the most
commonly reported sign (40%). In another
systematic review of 7780 pediatric patients, fever
(59%) and cough (55%) were the most frequent
symptoms.6 In this review, 89.7% of children were
symptomatic, and immunocompromised children
or those with respiratory/cardiac disease
comprised the largest subset of COVID-19
patients with underlying comorbid conditions.
Underlying comorbid conditions are associated
with severe disease and the need for admission to
an intensive care unit.6,7 Majority of the published
data on COVID-19 in children comes from China,
the USA, and Europe. The data reported from
developing countries is mainly limited to case
reports or short case series, and is particularly
limited on children with comorbid conditions.5,6
Ethnicity, along with the presence of pre-existing
comorbidities, has also been proposed as an
independent risk factor for severe
disease.7Herein, we report the disease spectrum
and outcome of symptomatic children with
COVID-19 presenting to a single tertiary care
hospital in a developing country, with special
reference to children with comorbid conditions.
MATERIAL AND METHODS
This was a descriptive cross-sectional study
conducted from March 15 to July 31, 2020 at The
Children’s Hospital Lahore, Pakistan. The study
participants were children from 1 day to 16 years
old who were admitted to the hospital. The
307
Institutional Review Board approved the study and
written informed consent was obtained from the
parents. Demographic and clinical data were
collected from patient records and entered on a
predesigned proforma. Nasopharyngeal or throat
swabs were taken from all children for reverse
transcription polymerase chain reaction (RT-
PCR). All patients with confirmed COVID-19 were
included in the study, and all children who had
negative RT-PCR results were excluded. The
diagnosis of COVID-19-associated MIS-C was
made as per the World Health Organization
(WHO) criteria; serology for antibodies to SARS-
CoV-2 antibodies was performed in these
patients.8 In all patients, information on the
demographic profile, number of positive family
contacts, indirect contact, international travel, or
contact with international traveller was collected.
Patient data, including age, sex, underlying
comorbidities, and the mode of presentation (i.e.
asymptomatic or symptomatic), were collected.
The disease severity was categorized as
asymptomatic, mild, moderate, severe, or critical
based on the operational definition as per the
WHO criteria.
Laboratory tests, including complete blood counts
with differential count, inflammatory markers,
including the erythrocyte sedimentation rate, C-
reactive protein (CRP), and serum ferritin and
procalcitonin, liver function tests, serum
electrolytes, renal function tests, D-dimers, partial
thromboplastin time/activated partial thrombo-
plastin time, arterial blood gases, chest X-ray,
electrocardiogram, echocardiography, ultrasound,
and chest computerized tomography scans were
performed according to the disease severity and
indications.
All children were treated according to the hospital
protocol and guidelines of the Corona Expert
Advisory Group (CEAG) notified by the
Government of Punjab. The mainstay of
management was supportive care and
oxygenation. Azithromycin was only used in
children with mild to moderate disease. Hydroxy
Chloroquine (HCQ) was not used, as the safety
www.pakpedsjournal.org.pk
 Ch A, Bari A, Rashid J, Alvi Y, Naz F, Rana N, Bano I, Qureshi A, Aamir K, Akhtar N,
308 Maqbool S, Ahmad N, Saleem M, Sadiq M

profile and the dose is not clear in children with TABLE 1: Epidemiological and clinical
different comorbidities. characteristics of children with symptomatic
COVID-19 (n= 42
Information regarding clinical outcomes at the
time of data closure included survival, the duration Characteristics Number (%)
of ventilation, and lengths of pediatric intensive Age, median (IQR), years:7.75 (1.3-11.2)
care unit (PICU) and hospital stays. The < 01 year 09 (22)
outcomes were declared as discharged, died, 01-05 years 08 (19)
transferred out, and under treatment. 05 -10 years 14 (33)
10-15 years 11 (26)
Data were analyzed using the statistical software
IBM SPSS-22. Quantitative variables, including Gender
age, the duration of stay and weight, are Male 19 (45)
presented as the mean and standard deviation Female 23 (55)
(SD). Qualitative variables, including family Contact with Positive COVID-19 cases
members who are positive or negative, clinical Direct/ indirect 30 (71)
presentation, disease severity, and outcome, are Parents Father/Mother 13 (31)
presented as frequency and percentages. The Siblings 03 (07)
independent t-test was used to explore the Other family members 10 (24)
differences in mean scores, and the Chi-square Travel or residence in high risk area 13 (31)
test was employed for categorical variables. P- Cluster cases of respiratory disease 02 (05)
values <0.05 were considered statistically No contact 12 (29)
significant. Disease Severity
RESULTS Mild-Moderate 30 (72)
Severe 09 (21)
A total of 74 children were admitted with Critical 03 (07)
confirmed COVID-19 and MIS-C over the study Symptoms
period; among them, 22 diagnosed with MIS-C Constitutional 33 (79)
and 10 asymptomatic children admitted for Respiratory 22 (52)
isolation were excluded from data analysis. The Gastrointestinal 06 (14)
median age of the 42 symptomatic children who Neurological 03 (07)
Circulatory 06 (14)
were positive for SARS-CoV-2 by RT-PCR was
7.5 years (IQR, 1.3–11.2 years), and there was COVID-19: Coronavirus disease 2019, IQR:
Interquartile Range
slight female preponderance (55%). The median
age of children with comorbid conditions was Chronic kidney disease (CKD) was the most
higher than those without any pre-existing common underlying comorbid condition (07/19-
comorbidity (10 vs. 4 years). The majority of 37%), and obstructive uropathy, nephronophthisis,
children (n=30, 71%) had been in direct contact renal calculi, glomerulonephritis, and primary
with a COVID-19 positive person (table 1). hyperoxaluria were the underlying etiologies of
patients with CKD. These patients were initially
The predominant constitutional symptoms were managed with peritoneal dialysis, followed by
fever (n=33, 79%) and respiratory symptoms regular hemodialysis when arrangements for
(n=22, 52%), followed by gastrointestinal hemodialysis were made. Six patients with CKD
symptoms (n=06, 14%). Of these symptomatic were discharged or referred back to the
children, 72% of cases had mild to moderate nephrology unit. The other underlying comorbid
symptoms, 21% had severe symptoms, and 7% conditions are tabulated in table 2. The various
were critical. All critical patients had a pre-existing surgical comorbid conditions included
comorbid condition. A higher proportion of infants bronchopulmonary fistula, ileostomy, fracture
were symptomatic (22%). mandible, leg fracture, and post-appendectomy.

www.pakpedsjournal.org.pk
 Comorbidity and COVID-19 in Children - A Single Center Experience 309

TABLE 2: Disease severity & outcome of children with all comorbidities (n=19)
Comorbidities Mali- CLD Diabetes Surgical Cerebral p-value
Variables CKD CHD gnancy( (n=1) Mellitus Conditions Palsy
(n= 7) (n= 2) n=2) (n=1) (n=5) (n= 1)
Age
<01 year 0 (0) 02 (100) 01 (50) 0 (0) 0 (0) 01 (20) 0 (0) 0.083
1-5 yrs 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 01 (20) 0 (0) 0.814
5-10 yrs 01 (14) 0 (0) 0 (0) 0 (0) 01 (100) 03 (60) 01 (100) 0.148
10-15 yrs 06 (86) 0 (0) 01 (50) 01 (100) 0 (0) 0 (0) 0 (0) 0.037
Disease Severity
Mild- Moderate 04 (57) 02(100) 02(100) 01 (100) 01 (100) 0 (0) 01 (100) 0.063
Severe 02 (29) 0 (0) 01 (50) 0 (0) 01(100) 0 (0) 01(100) 0.171
Critical 1 (14) 0 (0) 01 (50) 01(100) 0 (0) 0 (0) 0 (0) 0.186
Outcome
PICU 05 (71) 02 (100) 02 (100) 0 (0) 01(100) 0 (0) 01(100) 0.045
Mortality 01 (14) 0 (0) 01 (50) 01(100) 0 (0) 0 (0) 0 (0) 0.186
CKD: Chronic kidney disease, CHD: Congenital Heart Disease, CLD: Chronic Liver disease, PICU: Pediatric
Intensive Care Unit

All children were treated according to the <01 year 05 (22) 04 (21) 1.000
guidelines issued by the CEAG. Since the children 01-05 years 07 (30) 01 (05) 0.039
had evidence of pneumonia, first line antibiotics 05-10 years 08 (35) 06 (32) 1.000
(ceftriaxone and co-amoxidave) were used in 10-15 years 03 (13) 08 (42) 0.033
most of our children to prevent secondary Disease Severity
bacterial infections. The children were then Mild-Moderate 19 (83) 11 (58) 0.049
switched to second line antibiotics (meropenum Severe 04 (17) 05 (26) 0.483
and vancomycin) if there was no clinical Critical 0 (0) 03 (16) 0.025
improvement, or if their clinical condition Symptoms
deteriorated. We did not use steroids initially, but
as the evidence emerged, we used Constitutional 18 (78) 15 (79) 0.957
Respiratory 13 (56) 09 (47) 0.554
dexamethasone in the management of moderate
Gastrointestinal 03 (13) 03 (16) 0.800
to critical patients. Anticoagulation, in the form of
Neurological 0 (0) 03 (16) 0.048
low‐molecular weight heparin, was used when Circulatory 01 (06) 05 (29) 0.072
there was risk of thromboembolism or a high
amount of D-dimers. Patients with underlying Pharmacotherapy
comorbid conditions required prolonged intensive Azithromycin 10 (43) 03 (16) 0.053
care monitoring (p=0.020), and the need for 1st line I/V 14 (61) 07 (37) 0.121
mechanical ventilation was also significantly antibiotics
higher than in children with no comorbidity 2nd line I/V 07 (30) 12 (63) 0.034
(table3). antibiotics
TABLE 3: Comparative characteristics of children Treatment
with COVID-19 and underlying comorbidities Vasoactive 01 (06) 05 (29) 0.043
support
COVID-19
Oxygen therapy 07 (30) 09 (47) 0.261
COVID-19 with p-
(nasal)
Variables n= 23 comor- value
Ventilatory support 0 (0) 03 (16) 0.048
bidities
n=19 Hospital Stay & Outcome
Gender Duration of stay, 9.9 ± 6.2 12.5± 7.7 0.242
Males 10 (43.5) 09 (47) 0.801 mean (SD) days
Females 13 (56.5) 10 (53) PICU requirement 07 (30) 12 (63) 0.034
Age Mortality 0 (0) 03 (16) 0.048
Age, mean (SD), 5.3 ± 4.3 8.3 ± 5.0 0.049 COVID-19: Coronavirus disease 2019, PICU: Pediatric
years Intensive Care Unit

www.pakpedsjournal.org.pk
 Ch A, Bari A, Rashid J, Alvi Y, Naz F, Rana N, Bano I, Qureshi A, Aamir K, Akhtar N,
310
All patients were discharged successfully, with the
exception of three who died. The children with
other underlying comorbid conditions were
managed successfully and were discharged on
their respective department’s follow-up (table 2).
In the current study, there were three fatalities
(7%), all of which had a comorbid condition
(p = 0.032). The first death was a child with CKD
due to obstructive uropathy, who presented with
refractory fluid overload, hypertensive emergency
(190/140), respiratory distress, severe persistent
metabolic acidosis, high ferritin, and raised CRP.
Peritoneal dialysis was performed but the patient
died after a hospital stay of less than 48 hours
despite supportive care. The second death was a
patient with chronic liver disease (CLD) who was
critically sick with markedly deranged liver
function test and a deranged coagulation profile.
The patients’ hepatitis B and hepatitis C profile
and workup for Wilson disease was negative, and
her death was due to massive uncontrolled
gastrointestinal bleeding and hepatic
encephalopathy. The third death was a 4-month-
old infant with hyper-IgE (Hyper-
immunoglobulinemia E) syndrome, who had a
history of severe eczematous rash since the age
of 2 months and a serum IgE level of 79,000. He
had a late presentation (after being admitted and
treated in multiple local hospitals), with severe
pneumonia, very high complete blood counts,
normal bone marrow, thrombocytopenia, and a
prolonged coagulation profile. He remained
critically sick and developed respiratory failure
requiring mechanical ventilation. His death was
due to fulminant pneumonia, sepsis, and
disseminated intravascular coagulation (DIC).
DISCUSSION
Data on COVID-19 in children from developing
countries are limited, and the published data do
not reflect the global pattern of this disease in
children.8,9 Children account for approximately 5%
of the total patients diagnosed with COVID-19,
and the disease in children is mild, with less than
1% of hospital admissions.10 The overall infectivity
rate of the population <20 years of age is
disproportionately high in Pakistan (10.3%). One
plausible explanation could be an unusual virus
spread through cultural, behavioral, and societal
differences, including a lower socioeconomic
www.pakpedsjournal.org.pk
Maqbool S, Ahmad N, Saleem M, Sadiq M
status, health-seeking behavior, and
intergenerational cohabitation. The Pakistan
population pyramid is also different than that of
the developed countries, and almost 47% of the
total population is under 18 years of age.11
Ethnicity may also be a factor, as has been
reported from countries with diverse ethnic
populations.12
In our study, the median age of the patients was
7.75 years, which is comparable to the majority of
previously reported data.8 A much lower age has
been documented in studies from China, which
have shown a median age of 3 years.13,14
However, our data show a clear difference
between the group with no comorbidity and the
comorbid group (4 vs. 10 years). This difference in
age groups between the two groups is related to
the fact that the majority of children with
comorbidities had CKD and presented after 5
years of age.15 This higher age in children with
comorbid conditions closer to the data reported
from the US and Canadian PICUs, where the
median (range) age was 13 (4.2–16.6) years.16
There was only a slight female predominance in
our study (55%); however, the majority of previous
epidemiological studies show a male
predominance in the pediatric age group.8,9
Contact with a COVID-19 positive person is an
important factor in suspecting COVID-19 in
children. Indeed, we found definite direct or
indirect contact in 71% of our cases. A similar
study on COVID-19 in children showed a positive
history of contact in 65% of thechildren.17
Furthermore, a study from Iran demonstrated that
only 36.7% of cases had a definite contact with a
confirmed or probable COVID-19 case.18 Family
clustering has also been reported in children
presenting with COVID-19, demonstrating that
family members with COVID-19 increase the risk
of COVID-19 in children.19 The risk of transmission
of COVID-19 is high among household contact
and non-household contact during social
gatherings. The social and family structure of
Pakistan may be an important factor for the high
burden observed in children and adolescents.
In the current study, there were a significant
number (n=19, 45%) of children with underlying
comorbid conditions, the most common of which
was CKD, followed by surgical conditions and
congenital heart disease (CHD). In a study from
 Comorbidity and COVID-19 in Children - A Single Center Experience
North America PICUs, 83% of the patients had
significant pre-existing comorbidities.16 Moreover,
a large multicenter study on 587 children under 18
years old from European countries focused on the
factors associated with the need for PICU
admission, and 22% of these children had
underlying comorbidities. Pre-existing medical
conditions, age lower than 1 month, and signs of a
lower respiratory tract infection at presentation
were significant risk factors for PICU admission.
The most common underlying conditions were
chronic pulmonary disease, including asthma
(45%) and CHD (23%), immune suppression
(12%), and hematologic or oncologic conditions
(6%).20 Chronic pulmonary disease was also the
most commonly reported underlying condition in
children from the United States with laboratory-
confirmed COVID-19.21 The CDC's COVID-NET
data provides information on underlying medical
conditions in hospitalized children from 14 states;
by the end of July 2020, 42% had ≥1 underlying
condition, the most common of which were
obesity (38% of children ≥2 years), chronic
pulmonary disease (18%), and prematurity (15%
of children <2 years).6 Similar findings of
underlying comorbid conditions were noted in a
systematic review, which showed that 35.6% of
COVID-19 positive children had some form of
underlying medical condition.6
In our series, the mortality rate of children with
comorbid conditions was high (3/19). One of our
initial limiting factors was the lack of a
hemodialysis facility in our COVID-19 unit for CKD
patients; instead, these patients underwent
regular peritoneal dialysis, which would have
increased the risk of nosocomial infections.
Furthermore, CKD poses a greater risk for severe
disease with COVID-19 because of a greater
chance of infections, ICU admission, and
mechanical ventilation.15 Other common risk
factors include a thrice weekly dialysis schedule,
compromised immune system, immune-
suppressive drug use, chronic malnutrition, and
anemia, all of which were relevant in our
patients.22 Multiple factors were responsible for
the death of the child with CKD. He had a delayed
presentation to the hospital due to lockdown;
hence, he missed two hemodialysis sessions and
had severe volume overload, hypertensive
emergency, metabolic acidosis, and electrolyte
imbalance. Consequently, he developed a severe
311
chest infection and died. The second death was a
case of CLD with unknown underlying etiology.
She presented in a critically sick condition with
massive abdominal distension and ascites.
Underlying liver disease is a recognized risk factor
for severe COVID-19 infection, and patients with
decompensated cirrhosis have an increased
chance of mortality from COVID-19.23 Data from
adult cases have shown a high prevalence of CLD
in COVID-19 patients (2% to 11%), with an
increased chance of developing liver damage,
with more adverse morbidity and mortality.24 The
third child who died had hyper-IgE syndrome,
which was most likely autosomal recessive, with a
very late presentation and delayed diagnosis. He
was also critically sick with severe respiratory
distress followed by respiratory failure that
required mechanical ventilation. He died due to
fulminant pneumonia, sepsis, and DIC. Moreover,
immune deficiency is reported as a significant risk
factor in children with severe COVID-19
infection.25
The factors common to all three patients and
specific to countries with limited resources include
a delayed presentation, often with a very sick
condition, and fulminant co-infection potentially
leading to death.
Limitations and Strengths: This was a single
center study, which limits the generalizability of
the results. However, the Children’s Hospital
Lahore is the largest referral center for children in
Pakistan and provides a comprehensive picture of
pediatric patients with COVID-19 in Pakistan.
CONCLUSIONS
COVID-19 in children is generally mild with a good
outcome. CKD was the most common comorbidity
in our series, and underlying comorbid conditions
are a major risk factor for prolonged hospital stay
and a poor outcome. These initial findings provide
important data from a developing country and
provide a platform for larger, more extensive
studies in children with COVID-19 and
comorbidities.
Conflict of Interest Disclosures: None
Grant Support & Financial Disclosures: None.
--------------------------------------------------------------------------
Authors’ affiliation
Aimen Ch, Attia Bari, Prof. Junaid Rashid,
www.pakpedsjournal.org.pk
 Ch A, Bari A, Rashid J, Alvi Y, Naz F, Rana N, Bano I, Qureshi A, Aamir K, Akhtar N,
312
Prof. Yasin Alvi, Farrah Naz, Nasir Rana, Iqbal Bano,
Abid Qureshi, Khalida Aamir, Naureen Akhtar, Prof.
Shazia Maqbool, Prof. Nisar Ahmad, Prof.
Muhammad Saleem, Prof. Masood Sadiq
The Children’s Hospital and The Institute of Child
Health, Lahore, Pakistan
REFERENCES
1. “Coronavirus in Pakistan – Confirmed Cases”.
www.covid.gov.pk/. Retrieved 09 July 2020.
2. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et
al. Epidemiology of COVID-19 Among Children
in China. Pediatrics. 2020; 145(6):e20200702.
3. Feldstein LR, Rose EB, Horwitz SM, Collins JP,
Newhams MM, Son MBF, et al. Multisystem
Inflammatory Syndrome in U.S. Children and
Adolescents. N Engl J Med. 2020; 83(4):334-
346.
4. Sadiq M, Aziz OA, Kazmi U, Hyder N, Sarwar M,
Sultana N, et al. Multisystem inflammatory
syndrome associated with COVID-19 in children
in Pakistan. The Lancet Child and Adolescent
Health. 2020. 4 (10):e36-e37.
5. Liguoro I, Pilotto C, Bonanni M, Ferrari ME,
Pusiol A, Nocerino A, et al. SARS-COV-2
infection in children and newborns: a systematic
review. Eur J Pediatr. 2020;1-18.
6. Hoang A, , Chorath K, Moreira A, Evans M,
Morton FB, Burmeister F et al. COVID-19 in
7780 pediatric patients: A systematic review.
EClinicalMedicine. 2020; 24:100433.
7. Harman K, Verma A, Cook J, Radia T,
Zuckerman M, Deep A, et al. Ethnicity and
COVID-19 in children with comorbidities. Lancet
Child Adolesc Heal. Elsevier Ltd; 2020;4(7):e24–
5.
8. Dong Y, Dong Y, Mo X, Hu Y, Qi X, Jiang F, et
al. Epidemiology of COVID-19 among children in
China. Pediatrics. 2020. 145(6):e20200702.
9. Hong H, Wang Y, Chung HT, Chen CJ. Clinical
characteristics of novel coronavirus disease
2019 (COVID-19) in newborns, infants and
children. Pediatr Neonatol. 2020;61(2):131–2.
10. Ludvigsson JF. Systematic review of COVID-19
in children shows milder cases and a better
prognosis than adults. Acta Paediatr. 2020;
109(6):1088-1095.
11. UN Department of Economics and Social Affairs.
World Population Prospects - Population Division
- United Nations. The International Journal of
www.pakpedsjournal.org.pk
Maqbool S, Ahmad N, Saleem M, Sadiq M
Logistics Management. 2015.
12. Pareek M, Bangash MN, Pareek N, Pan D, Sze
S, Minhas JS, et al. Ethnicity and COVID-19: an
urgent public health research priority. The
Lancet. 2020. 3 95(10234):1421-1422.
13. Zheng F, Liao C, Fan Q hong, Chen H bo, Zhao
X gong, Xie Z guo, et al. Clinical Characteristics
of Children with Coronavirus Disease 2019 in
Hubei, China. Curr Med Sci. 2020; 40(2):275-
280.
14. Liu W, Zhang Q, Chen J, Xiang R, Song H, Shu
S, et al. Detection of Covid-19 in children in early
January 2020 in Wuhan, China. New England
Journal of Medicine. 2020. 382(14): 1370–1371.
15. Henry BM, Lippi G. Chronic kidney disease is
associated with severe coronavirus disease
2019 (COVID-19) infection. International Urology
and Nephrology. 2020; 52(6):1193–4.
16. Shekerdemian LS, Mahmood NR, Wolfe KK,
Riggs BJ, Ross CE, McKiernan CA, et al.
Characteristics and outcomes of children with
coronavirus disease 2019 (COVID-19) infection
admitted to US and Canadian pediatric intensive
care units. JAMA Pediatr. 2020; 1948:1–6.
17. Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D.
Clinical and CT features in pediatric patients with
COVID-19 infection: Different points from adults.
Pediatr Pulmono. 2020; 55(5): 1169–1174.
18. Soltani J. Pediatric Coronavirus Disease 2019
(COVID-19): An Insight from West of Iran. North
Clin Istanbul. 2020;7(3):284–91.
19. Ji LN, Chao S, Wang YJ, Li XJ, Mu XD, Lin MG,
et al. Clinical features of pediatric patients with
COVID-19: a report of two family cluster cases.
World J Pediatr. 2020; 16:267–270.
20. González-Dambrauskas S, Vásquez-Hoyos P,
Camporesi A, Díaz-Rubio F, Piñeres-Olave BE,
Fernández-Sarmiento J, et al. Pediatric critical
care and COVID19. Pediatrics. 2020; 146 (3):1-
5.
21. Stokes EK, Zambrano LD, Anderson KN, Marder
EP, Raz KM, El Burai Felix S, et al. Coronavirus
Disease 2019 Case Surveillance — United
States, January 22–May 30, 2020. MMWR Morb
Mortal Wkly Rep. 2020; 69(24):759-765.
22. Feng S, Xie M, Luo W, Wang L, Guo L, Wu Y, et
al. Prevention and Control of COVID-19 in
Chronic Kidney Disease. Indian Journal of
Pediatrics. 2020; 87: 968–969.
23. Moon AM, Webb GJ, Aloman C, Armstrong MJ,
 Comorbidity and COVID-19 in Children - A Single Center Experience
Cargill T, Dhanasekaran R, et al. High mortality
rates for SARS-CoV-2 infection in patients with
pre-existing chronic liver disease and cirrhosis:
Preliminary results from an international registry. 25.
Journal of Hepatology. 2020;73(3):705-708.
24. Su TH, Kao JH. The clinical manifestations and
management of COVID-19-related liver injury.
View publication stats
313
Journal of the Formosan Medical Association.
2020. 119(6):1016–1018.
Boulad F, Kamboj M, Bouvier N, Mauguen A,
Kung AL. COVID-19 in Children with Cancer in
New York City. JAMA Oncol. 2020;6(9):1459-
1460.
www.pakpedsjournal.org.pk