Demographic and medical past history data
Of the total number of 325 pediatrics patients, 189 (58%) and 136 (42%) were males and females, respectively (Table 1). The age of subjects ranged between 0 and 15 years old; the mean age was 6.18 ± 4.99. There was no significant correlation between the distributions of cases in different age groups (P-value 0.85, Table 1). A majority of patients had a history of close contact with COVID-19 patients and/or travel to provinces with a high prevalence of COVID-19 (results not shown).
Regarding the vaccine history of patients, 300 (92.4%) had received all routine childhood vaccines, and 25 (7.6%) received incomplete vaccination in fear of high-risk disease transmission in the health care centers. Previous medications (before the admission), including antibiotic therapy, corticosteroid therapy, and chemotherapy were reported in 117 (36%), 33 (10.2%), and 32 (9.8%) of patients, respectively (Table 1).
323 patients had at least one symptom before the admission, while only 2 of the cases did not have any symptoms. 236 (72.6%) had a fever. The common respiratory symptoms were cough (59%), shortness of breath (36%), sore throat (6.15%), and rhinorrhea (4%). Gastrointestinal (GI) symptoms were seen in 254 (78% (of patients including nausea/ vomiting (31.38%), anorexia (26.8%), diarrhea (13.84%) and abdominal pain (6.15%). 145 (44.6%( of children had neurological symptoms including, fatigue (17.5%), drowsiness/ loss of consciousness (12%), seizure (6.15%), headache (5.8%) and myalgia (3.07%). Eleven (3.38%) of patients experienced different kinds of skin rash. Among the above symptoms, only shortness of breath and rhinorrhea were significantly associated with the disease severity (P values 0.001 and 0.033, respectively, Table 1).
Upon clinical examination, grunting (P-value 0.004), intercostal and subcostal retractions (P-value <0.001), nasal flaring (P-value <0.001), as well as respiratory fine crackles (P value, 0.001), were significantly associated with the disease severity (Table 1). Other signs including, wheezing, coarse respiratory crackles, and cyanosis, did not substantially correlate with disease severity (Table 1).
In the process of interpretation and analyzing the data, there was a high percentage of heterogeneity in the hematological and biochemistry results. Taken into consideration, to avoid any false data outputs, we have decided to exclude some of our unreliable results. As it can be clearly seen from the Table-1, the presented results have undergone excessive shrinkage.
166 (51%) of patients showed positive RT results obtained from at least one of the upper respiratory tract specimens. 159 (49%) of patients had negative PCR results on the initial testing. There was no significant association between the positivity of PCR results and the clinical outcome of subjects (P-value 0.5, Table 1).
The hematological assessment showed that a decrease in platelet counts, together with increase C-reactive protein values had substantial correlations with the disease outcomes (P values 0.015 and 0.038, respectively, Table 1). Among a list of biochemistry results, only increased values of LDH (P value, 0.007) and blood urea nitrogen (P value, 0.003), showed insignificant associations with illness severity (Table 1).
Blood saturation results
At the beginning of the pandemic and due to the shortage of facilities in some hospitals, blood saturation tests were carried only for 148 patients. A decrease in the blood PH and HCo3 was associated with the illness severity (P values 0.004 and 0.003, respectively, Table 1). However, Po2 and PCo2 levels had no significant correlation with the disease outcome (Table 1).
Overall, of 232 patients who undertook chest X-ray, 58.2% showed abnormal radiographic appearance, whereas, in the chest CT scan from 205 subjects, 65.4% showed abnormal features. Statistics showed that both chest X-ray and CT scan abnormal results had significant correlations with disease severity (P values <0.001 and 0.029, respectively, Table 1). Ground glass opacity (44%), lung consolidation (26%), peripheral airspace opacities (25%), patchy infiltration (19%), and pleural effusion (9%), were the common radiological findings of which; the first two formers had significant correlations with illness severity (P values 0.029 and 0.009, respectively, results not shown).
Table 2 and figure 1 show the correlation between different age groups and disease severity. 195 (60%) and 130 (40%), had moderate and severe conditions, respectively (Table 1). No significant correlation was found between different age groups of patients and death (P-value 0.4, Table 2). In total, 135 (41.5%) of patients had a history of at least one underlying disease. Table 1 describes the details of those morbidities. Malignancies (36, 26.6%), and heart disease (14, 10.3%) were amongst the commonest comorbidities among the cases. Other morbidities were included: asthma (6, 4.44%), cystic fibrosis (2, 1.48, %), chronic kidney diseases (7, 5%), diabetes (2, 1.48%), failure to thrive (9, 6.66%) and other medical conditions (57, 42.2%) (Table 1). 45 (13.9%) of patients died. The only significant criterion for deceased patients was the presence of comorbidity (P-value <0.001, Table 3).
Due to 104 (32%) patients’ critical condition, they were referred to ICU (Table 3). The only factor which was correlated with ICU referrals was the presence of comorbidity (P-value 0.003, Table 3). No significant correlation was found between the age group and referral to ICU (P-value 0.2, Table 2). No other clinical symptoms, laboratory parameters, and radiological findings were associated with ICU admission (results not shown).
Oxygen therapy was used for 121 (37.2%) of patients. 78 (24%) of patients experienced at least one clinical severe outcome as the followings: ARDS 35 (10.7%), shock 18 (5.5%), acute cardiac injury 11 (3.38%), arrhythmia 7 (2.2%), and acute kidney injury 7 (2.2%). Justification of these outcomes with the history of comorbidities showed that subjects who were had at least one underlying disease suffered from shock (P value, 0.003), arrhythmia (P value,0.13), acute kidney injury (P value, 0.13), ARDS (P value, <0.001) and acute cardiac injury (P value, 0.057%).
Upon justifying with different age groups, ARDS’s only occurrence showed a significant correlation (P value 0.015, Table 2). No other clinical outcome or parameters was associated with the patients' age (Table 2).
During hospitalization, 262 (80.6%) patients received different antibiotics either for treatment or prophylaxis against bacterial infections. 72 (22%) did not receive any treatment. Hydroxychloroquine was the basis and the drug of choice as the initial treatment in 208 (64%) patients (Table 4). Different antivirals, with or without the combination of hydroxychloroquine or naproxen, were advocated for 253 (78%) of patients with both moderate and severe conditions (Table 4). Nevertheless, for a majority of severe cases, different cocktails of drugs were used (Table 4). Even more, oseltamivir was prescribed for 27 (8.3%) patients based on the initial suspension for influenza infection. However, in a majority of those included in the severe type of the disease, no significant improvements were seen for those who progressed to death (results not shown).