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expert reaction to an urgent alert has been issued to doctors about a serious coronavirus-related condition in children

An urgent alert has been issued to doctors by the Paediatric Intensive Care Society (PICSUK) regarding a serious coronavirus-related condition in children.


Prof Sheila Bird, Formerly Programme Leader, MRC Biostatistics Unit, University of Cambridge, said:

“Recently published data from Iceland (Gudbjartsson DF et al, NEJM 2020; April 14th) on spread of SARS-CoV-2 in the Icelandic Population warn that children under 10 years of age can be infected.

“From 31 January 2020 to 31 March, Iceland did targeted swab testing (have I got it?) of those returning from high risk countries or who had been in contact with infected persons: 7% of those under 10 years of age (38/564, 95% CI: 4.7% to 8.8%) were swab-positive in targeted testing.

“Open invitation population screening, taken up mainly in the capital area, was offered through online registration during 13 March to 1 April to Icelanders who were symptom-free or had mild symptoms of the common cold: 87/10,079 (0.8%, 95% CI: 0.6% to 1.0%.) were swab-positive. This open invitation screening included 848 children under 10 years of age, none of whom tested swab-positive (upper 95% confidence limit of 0.35%).

“The Icelandic paper also showed a shift in the distribution of SARS-Cov-2 haplotypes – small variances in the viral genome as it mutates – according to the timing of diagnosis and, within each diagnostic time period, imported or local transmission. This is a useful tool in helping to track the spread of infections.

“Haplotypes of the COVID-19 virus have not yet been linked to symptom severity or worse symptoms, but research into this will be carried out.  As in the Icelandic study, such shifts in dominant haplotypes are likely to occur in other countries too.

“Despite generally low infection rates in young children (as in Iceland), shift in haplotype of the currently-locally-transmitting coronavirus-2 could possible explain why certain symptoms of the virus may come to light later on in an outbreak.

“However, it’s important to note that infected children have a very low chance of being seriously affected in any observed cohort so far and so it may simply be that, as the pandemic progresses, we are see  these rare events simply because we have seen many more cases of COVID-19 generally.

“A disconcerting third reason is that possible COVID-19 deaths in children – because so unusual –  may have been referred for inquest. In England & Wales, the Office for National Statistics does not become aware of inquest-deaths until weeks or months later: only when the coroner determines cause of death. In Scotland, by contrast fact-of-death must be registered for all deaths with National Records of Scotland (NRS) within 8 days of death having been ascertained. NRS can then follow-up to ascertain information about the putative cause of death, such as in a pandemic when the death concerns a child.

“In the aftermath of swine-flu in 2009/2010, the Royal Statistical Society called for legislation to end the late registration of fact-of-death in England & Wales (and in Northern Ireland). Sadly we have been overtaken by the COVID-19 pandemic in 2020 before legislation was laid.”


Prof Ian Jones, Professor of Virology, University of Reading, said:

“We need more data on the suggested link between SARS-CoV-2 and a widespread state of hyper-inflammation, especially in children. A general inflammatory syndrome was reported for selected Covid-19 patients recently in University Hospital Zurich and curiously, a general inflammation of blood vessels in children, Kawasaki disease, was once suggested to be linked to a related coronavirus, NL63, which uses the same receptor as SARS-CoV-2, although this was later found not to be the case. It’s too early to know if this is distinct aspect of SARS-CoV-2 or, for example, something else noted by the extended confinement with observant parents.”


Professor Russell Viner, President of the Royal College of Paediatrics and Child Health, said:

“We already know that a very small number of children can become severely ill with COVID-19 but this is very rare – evidence from throughout the world shows us that children appear to be the part of the population least affected by this infection. 

“New diseases may present in ways that surprise us, and clinicians need to be made aware of any emerging evidence of particular symptoms or of underlying conditions which could make a patient more vulnerable to the virus.

“However our advice remains the same: parents should be reassured that children are unlikely to be seriously ill with COVID-19 but if they are concerned about their children’s health for any reason, they should seek help from a health professional.”

See here for more information: Guidance for parents on symptoms and seeking advice.


Professor Adilia Warris, Paediatric Infectious Diseases Specialist, University of Exeter, said:

What do we currently know about COVID-19 in children?

“Children have so far accounted for between 1% and 5% of diagnosed COVID-19 cases, have often milder disease than adults and deaths have been extremely rare.

“The largest series of paediatric cases originates from China, with 5.6% of 2143 children showing severe disease (e.g. needing oxygen), and 0.6% needing intensive care treatment.

“So far, children with underlying compromised immune systems or using immunosuppressive treatments (corticosteroids) are not at increased risk for developing severe Covid-19 disease.

“Children are unlikely to contribute to the transmission of COVID-19 in the population.

Is this likely to be COVID-19 or another, as yet unidentified, infectious pathogen?

“As we don’t know yet the full range of clinical presentations caused by COVID-19, we keep every possibility open that clinical presentations which can’t be explained by other causes, might be caused by COVID-19, or even a not yet recognized pathogen. As the inflammatory presentations referred to in the news, which a look-a-like with severe sepsis in children, asks for targeted management related to the causative pathogen, we consider both COVID-19 as well as a yet unrecognized pathogen in our differential diagnostic considerations.

“Please do consider that the absolute number of those cases are very low (a hand full at the moment). The call to ask if other colleagues have comparable experiences over the last week is so we are able to define what is going on, and if there is reason for additional assessment into this.

What is a multi-system inflammatory state?

“A clinical presentation where a lot of cytokines are produced which de-arrange a number of body functions, but the most important being leading to leaky blood vessels, causing low blood pressure and fluid accumulation in the lungs and other organs being in urgent need of intensive care treatment to support the function of the heart and the lungs (and sometimes other organs as well like the kidneys).

How much do we know about this condition? What do we need to know?

“What is the underlying cause, and how to best treat it.

Should people be worried?

“No, but as emphasized by the royal college for child health and paediatrics, if parents have genuine concerns about the health of their child, they should contact the GP and/or paediatrician.”


Prof Rosalind Smyth, Director and Professor of Child Health, UCL Great Ormond St Institute of Child Health, said:

“We know, from the evidence to date (published case series) that most children with COVID-19 who have come to medical attention have mild symptoms.  Around half of children have a fever and about 40% have a cough.  In reported case series, fewer than 10% have gastrointestinal symptoms.  However, our understanding of this condition in children is limited.  COVID-19 does present, in adults, as an inflammatory disease affecting a number of organs.  We should investigate fully these children, with SARS-CoV-2, who present with a multi-system inflammatory disease to assess whether this is a presentation of COVID-19.”


Dr James Gill, Honorary Clinical Lecturer, Warwick Medical School, and Locum GP, said:

“Whilst this coronavirus has spread like wild fire around the globe, there has been one continual factor that has provided relief for medical teams around the world – children, so far, have not been significantly unaffected by COVID-19, with only sporadic case reports, and then the affected children have been reported as having milder symptoms compared to adults.

“A new alert has been raised about a signal, a notable change, marking an increase in children being admitted to hospital with a ‘multi-system inflammatory state’. A clinical signal does not mean there is a new finding, it does however work as an alter to clinicians to be vigilant in case there is anything substantive behind that signal. This cannot be stressed enough

“Regardless of source, multi-system inflammatory diseases are exceptionally serious for children and already stretched intensive care teams, so keeping an extra eye out for new symptoms arising in the patients we see if always a good thing.

“Whilst it is easy to draw conclusions suggestive of a connection with COVID19 there is not sufficient evidence to substantiate that the signal has any clinical significance.

“The PHE surveillance guidance on children with regard to COVID19 does not currently mentioned issues with a multi-system inflammatory response. COVID-19 is a new condition from a novel virus, so we must remain vigilant to changes in clinical pictures, but also be guided by confirmed data, which is currently lacking

“In many ways, there is no change here. Clinically health professionals have a heads up about possible presentations, but will not change their current high level of caution. From the public perspective, the advice is a doubling down of current guidance:

– Stay in side, Stay safe

– The NHS is open for business, if you are worried about symptoms for yourself, or your children, call us.”


All our previous output on this subject can be seen at this weblink:


Declared interests

Prof Sheila Bird: SMB leads for the Royal Statistical Society on the need for legislation to end the late registration of deaths in the UK outside of Scotland.

None others received.

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