Abstract
This cohort study assesses the incidence of coronavirus disease 2019 (COVID-19) in pediatric patients presenting for surgery at 3 tertiary care children’s hospitals across the US.
The coronavirus disease 2019 (COVID-19) pandemic continues to spread, with more than 4.6 million confirmed cases worldwide as of May 19, 2020. Children appear less susceptible, with the Chinese Center for Disease Control and Prevention reporting that children constitute only 2.16% of confirmed cases.1 This may underestimate the true incidence of COVID-19 in children. Children are more likely to be asymptomatic or mildly symptomatic and thus less likely to be tested. The purpose of this study was to determine the incidence of COVID-19 in pediatric patients presenting for surgery at 3 tertiary care children’s hospitals across the United States.
Methods
After universal preoperative screening for COVID-19 was instituted at the Children’s Hospital of Philadelphia in Philadelphia, Pennsylvania, Texas Children’s Hospital in Houston, and Seattle Children’s Hospital in Seattle, Washington, all children younger than 19 years without known COVID-19 were tested. Data collection across all 3 hospitals began March 26, 2020, and ended April 22, 2020. All 3 hospitals use an in-house laboratory-developed reverse transcriptase–polymerase chain reaction assay to detect the severe acute respiratory syndrome coronavirus 2 virus. Retrospective record review was performed for demographics, clinical symptoms, and laboratory results. Race and ethnicity were self-reported. The institutional review boards of all participating hospitals approved the investigation with waiver of consent and multicenter sharing of deidentified data. Mann-Whitney U test, χ2 test, Fisher exact test, and multivariate logistic regression were conducted. Statistical significance was set at 2-sided P value less than .05.
Results
Overall, 1295 pediatric surgical patients were included in this study, with a mean (SD) age of 7.35 (5.99) years. Overall incidence of COVID-19 was 0.93% (12 of 1295) (Table 1). However, there was a significant difference in incidence across hospitals, ranging from 0.22% (1 of 456) to 2.65% (9 of 339). Notably, at Children’s Hospital of Philadelphia, 5 of 9 patients with positive COVID-19 results were from a single township with a positive risk rate of 55.56% vs 1.51% (5 of 330) in all other patients (risk ratio, 36.67; P = .001). Of 12 patients with COVID-19, 6 (50%) had preoperative symptoms vs 157 of 1283 patients (12.24%) who tested negative for COVID-19 (Table 2). Fever (3 of 12 [25.0%] vs 72 of 1077 [6.7%]), rhinorrhea (2 of 12 [16.7%] vs 34 of 1204 [2.8%]), and known COVID-19 exposure (2 of 10 [20.0%] vs 12 of 715 [1.7%]) were more common in patients with COVID-19. On multivariate regression, age (odds ratio, 1.10; 95% CI, 1.00-1.23; P = .048) and American Society of Anesthesiologists emergent classification (odds ratio, 5.66; 95% CI, 1.70-17.80; P = .001) were associated with COVID-19.
Table 1. Demographics and Preoperative RT-PCR Result Stratified by Hospital.
| Characteristic | No. (%) | All 3 hospitals | ||
|---|---|---|---|---|
| Children’s Hospital of Philadelphia, Philadelphia, PA | Seattle Children’s Hospital, Seattle, WA | Texas Children’s Hospital, Houston | ||
| Surgical dates | March 26, to April 22, 2020 | March 26, to April 20, 2020 | March 30, to April 20, 2020 | March 26, to April 22, 2020 |
| Surgical patientsa | 339 (26.18) | 500 (38.61) | 456 (35.21) | 1295 (100) |
| Age, mean (SD), y | 7.00 (5.98) | 7.69 (6.28) | 7.25 (5.66) | 7.35 (5.99) |
| Male | 186 (54.87) | 266 (53.31) | 264 (57.89) | 716 (55.33) |
| Race | ||||
| White | 197 (58.11) | 269 (53.80) | 374 (82.2) | 840 (64.91) |
| Black | 55 (16.22) | 35 (7.00) | 59 (12.97) | 149 (11.51) |
| Otherb | 87 (25.66) | 196 (39.20) | 22 (4.84) | 305 (23.57) |
| Ethnicity | ||||
| Hispanic | 35 (10.57) | 87 (18.75) | 214 (47.24) | 336 (26.92) |
| Non-Hispanic | 296 (89.43) | 377 (81.25) | 239 (52.76) | 912 (73.08) |
| Surgical procedure typec | ||||
| Neurosurgery | 43 (12.68) | 26 (5.20) | 27 (5.92) | 96 (7.41) |
| Orthopedics | 54 (15.93) | 62 (12.40) | 72 (15.79) | 188 (14.52) |
| Plastics | 23 (6.78) | 01 (0.20) | 15 (3.29) | 39 (3.01) |
| Ophthalmology | 11 (3.24) | 15 (3.00) | 25 (5.48) | 51 (3.94) |
| Otolaryngology | 39 (11.50) | 73 (14.60) | 43 (9.43) | 155 (11.97) |
| Urology | 15 (4.42) | 39 (7.80) | 19 (4.17) | 73 (5.64) |
| General surgery | 97 (28.61) | 113 (22.60) | 167 (36.62) | 377 (29.11) |
| Cardiothoracic | 28 (8.26) | 17 (3.40) | 44 (9.65) | 89 (6.87) |
| Oral and maxillofacial surgery/dental | 3 (0.88) | 46 (9.20) | 10 (2.19) | 59 (4.56) |
| Interventional radiology | 4 (1.18) | 76 (15.20) | 0d | 80 (6.18) |
| Gastrointestinal | 35 (10.32) | 5 (1.00) | 31 (6.80) | 71 (5.48) |
| Oncology | 9 (2.65) | 4 (0.80) | 1 (0.22) | 14 (1.08) |
| Other | 3 (0.88) | 23 (4.60) | 6 (1.32) | 32 (2.47) |
| ASA physical status classification system | ||||
| 1 | 59 (17.61) | 105 (21.56) | 119 (26.10) | 283 (22.14) |
| 2 | 111 (33.13) | 157 (32.24) | 146 (32.02) | 414 (32.39) |
| 3 | 137 (40.90) | 187 (38.40) | 139 (30.48) | 463 (36.23) |
| 4 | 26 (7.76) | 37 (7.60) | 52 (11.40) | 115 (9.00) |
| 5 | 2 (0.60) | 1 (0.21) | 0 | 3 (0.23) |
| ASA emergent | 79 (23.30) | 64 (12.80) | 42 (9.21) | 185 (14.29) |
| Inpatiente | 80 (23.60) | 206 (41.20) | 58 (13.36) | 344 (27.02) |
| RT-PCR positive | 9 (2.65) | 2 (0.40) | 1 (0.22) | 12 (0.93) |
Abbreviations: ASA, American Society of Anesthesiologists; RT-PCR, reverse transcriptase–polymerase chain reaction.
Percentages were calculated from the total of all 3 hospitals.
The other category included Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaska Native, other, or declined to answer.
May have more than 1 procedure per surgical case, with sum greater than 100%.
Texas Children’s Hospital did not perform universal screening for procedures performed outside of the operating room.
Inpatient was defined as having been admitted to the hospital ≥2 days before surgery.
Table 2. Characteristics of Pediatric Surgical Patients by RT-PCR Result.
| Characteristic | RT-PCR, No./total No. (%) | P value | |
|---|---|---|---|
| Positive (n = 12) | Negative (n = 1283) | ||
| Age, mean (SD), y | 11.25 (6.39) | 7.32 (5.98) | .03 |
| Male | 8/12 (66.67) | 708/1282 (55.23) | .43 |
| Race | |||
| White | 9/12 (75.00) | 831/1282 (64.82) | .76 |
| Black | 1/12 (8.33) | 148/1282 (11.54) | |
| Othera | 2/12 (16.67) | 303/1282 (23.63) | |
| Hispanic | 2/12 (16.67) | 334/1236 (27.02) | .42 |
| ASA physical status classification system | |||
| 1 | 1/10 (10.00) | 282/1268 (22.24) | .78 |
| 2 | 5/10 (50.00) | 409/1268 (32.26) | |
| 3 | 3/10 (30.00) | 460/1268 (36.28) | |
| 4 | 1/10 (10.00) | 114/1268 (8.99) | |
| 5 | 0 | 3/1268 (0.24) | |
| ASA emergent | 6/12 (50.00) | 179/1283 (13.95) | .001 |
| Inpatientb | 3/12 (25.00) | 341/1261 (27.04) | .87 |
| Preoperative symptomsc | |||
| Any symptom | 6/12 (50) | 157/1283 (12.24) | .001 |
| Cough | 1/12 (8.33) | 51/1186 (4.30) | .41 |
| Fever | 3/12 (25.00) | 72/1077 (6.69) | .04 |
| Rhinorrhea | 2/12 (16.67) | 34/1204 (2.82) | .047 |
| Diarrhea | 1/12 (8.33) | 34/689 (4.93) | .46 |
| Conjunctivitis | 0/12 (0.00) | 3/989 (0.30) | .96 |
| Travel outside US | 0 | 6/740 (0.81) | .76 |
| Travel outside region | 0 | 10/320 (3.13) | .59 |
| Known exposure to COVID-19 | 2/10 (20.0) | 12/715 (1.68) | .001 |
Abbreviations: ASA, American Society of Anesthesiologists; COVID-19, coronavirus disease 2019; RT-PCR, reverse transcriptase–polymerase chain reaction.
The other category included Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaska Native, other, or declined to answer.
Inpatient defined as having been admitted to the hospital ≥2 days before surgery.
Patient may have more than 1 symptom. If symptom was not explicitly mentioned, this was treated as missing data.
Discussion
The overall incidence of COVID-19 in children undergoing preoperative universal screening was less than 1%. However, this varied greatly between the regions represented by our hospitals and even by township within the catchment area of a single hospital. While patients with COVID-19 were more likely to have preoperative symptoms, most notably fever and rhinorrhea, half of the patients with positive results had no symptoms. Additionally, some of the symptoms noted were easily attributed to unrelated conditions (eg, appendicitis).
There are several limitations to the study. While all 3 hospitals implemented standard preoperative screening for COVID-19 risk factors and symptoms, retrospective collection of these data was dependent on the quality of documentation. During the study, all 3 hospitals canceled elective surgery in anticipation of a surge. The incidence of COVID-19 in children requiring time-sensitive surgery may not represent the incidence in children undergoing elective surgery. Finally, while we attempted to capture all patients with COVID-19 even if surgery was postponed owing to positive testing, cases may have been missed, resulting in underestimation of true incidence.
Symptomatology is an inadequate differentiator in children. There are reports of children with high viral load who are asymptomatic.2 If children do have symptoms, they tend to be mild.3 According to a recent Pediatric Anesthesia Leadership Council survey of 41 responding centers, 56% implemented universal preoperative screening (Thomas Long, MD, Pediatric Anesthesia Leadership Council, email communication, April 19, 2020). As demonstrated here, the value of universal screening is greatest in areas with higher prevalence.4 As elective surgery resumes across the country, it is important to consider universal testing in the context of regional prevalence, local testing capability, and availability of personal protective equipment.
References
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