Evolution of International Pediatric Endoscopic Practice Changes During the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has drastically altered endoscopic practices. We initially reported the international impact of COVID-19 on pediatric endoscopic practice. This follow-up study aimed to assess changes 7 months following the initial survey to delineate practice change patterns as the pandemic evolved. METHODS: Pediatric gastroenterologists who responded to the initial survey were re-surveyed seven months later using Research Electronic Data Capture (REDCap). The survey recorded information on changes in pediatric endoscopic practice patterns, including COVID-19 screening and testing processes and personal protective equipment (PPE) utilization. Additionally, endoscopists' risk tolerance of COVID-19 transmission was evaluated. RESULTS: Seventy-five unique institutions from 21 countries completed surveys from the 145 initial responses (51.7% response rate). Procedural volumes increased at most institutions (70.7%) and most were performing previously postponed cases (90.7%). Ninety-seven percent of institutions were performing pre-endoscopy screening with 78.7% testing all patients. Many institutions (34.7%) have performed procedures on COVID-19 positive patients. There was significantly less PPE reuse (P  < 0.05) and fewer institutions recommending full PPE for all endoscopies (43.2% vs 59.2%, P = 0.013). Overall, pediatric endoscopists' risk tolerance of COVID-19 transmission is low. CONCLUSIONS: This is the first survey to highlight the evolution of pediatric endoscopic practices related to the COVID-19 pandemic, underscoring the need for ongoing pandemic-related guidance for pediatric endoscopic practice.

SARS-COV-2 INFECTION AND SEROCONVERSION IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS

Background: As the Coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continues to evolve, its influence on specific patient populations suffering from chronic disorders becomes increasingly important. Patients with inflammatory bowel disease (IBD) are commonly immunosuppressed with immunomodulators, biologics, and steroids. Therefore, IBD patients have been considered as a risk population for COVID-19. Yet, emerging epidemiologic data may indicate otherwise. It is still unclear, however, how COVID-19 infection affects IBD patients and how seroconversion against the virus might take place depending upon disease states and treatments. We describe a single center cohort of pediatric IBD patients with COVID-19, a subset of whom were tested for seroconversion subsequent to the laboratory test supported infection. Methods and Results: The electronic medical records of pediatric IBD patients who tested positive for SARS-CoV-2 by nasopharyngeal swab based PCR testing were included in the study. The clinical course of IBD, concurrent medications, COVID-19 related symptoms, SARS-CoV-2 testing date, and SARS-CoV-2 IgG antibody testing date and result were examined. A total of 13 pediatric IBD patients at Texas Children’s Hospital tested positive for SARS-CoV-2. Patient demographics and specifics of IBD disease and management are detailed in table 1. Management was not altered in any of these patients in response to the positive COVID-19 test. Seven (53.8%) had symptoms including fever, sore throat, fatigue, loss of taste, dizziness, loss of smell, abdominal pain, and/or diarrhea;six (46.2%) were asymptomatic. No patients required hospitalization attributed to COVID-19. Of the 13 patients, 6 (46.2%) have been already tested for seroconversion. Four (67.7%) had elevated SARS-CoV-2 IgG of whom 3 patients (50%) had acute and resolved symptoms;one (16.7%) had an ambiguous serology (reactive total IgG and IgM but negative IgG and IgM individually), and one (16.7%) had nonreactive antibody titers. Seroconversion was tested between 0.4, or 4 to 13.7 weeks after initial positive SARS-CoV-2 PCR testing. The close antibody testing at 0.4 weeks had the ambiguous results. Serologic testing for the additional cases is pending. Conclusions: We describe a cohort of pediatric IBD patients with COVID-19 ranging from 1 week to 4 months after infection whose disease course has not been significantly affected. A large proportion of patients tested for seroconversion were found to mount a detectable IgG based immune response in spite of their medical immunosuppression. More research needs to be performed to evaluate the importance of seroconversion with relation to disease course andCOVID-19 reinfection in pediatric IBD patients. [Formula presented]

High Seroconversion Rate Against Severe Acute Respiratory Syndrome Coronavirus 2 in Symptomatic Pediatric Inflammatory Bowel Disease Patients.

ABSTRACT: Understanding coronavirus disease 2019 (COVID-19) in pediatric inflammatory bowel disease (PIBD) is important. We describe a single-center cohort of COVID-19 PIBD patients where seroconversion against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was examined.Immunosuppressed PIBD patients at Texas Children's Hospital who tested positive for SARS-CoV-2 by nasopharyngeal reverse transcriptase polymerase chain reaction were included in the study. The clinical course of IBD, concurrent medications, COVID-19 related symptoms, SARS-CoV-2 testing date, and SARS-CoV-2 immunoglobulin G (IgG) antibody testing date and result were examined. Of 14 SARS-CoV-2 positive PIBD patients, 12 were tested for qualitative anti-SARS-CoV-2 IgG (seven with transient COVID-19 symptoms, five asymptomatic). All symptomatic (7/7) and 60% of asymptomatic (3/5) patients seroconverted. No patients required hospitalization attributed to COVID-19.High rates of COVID-19 seroconversion occurred in immunosuppressed and symptomatic PIBD patients. More research to evaluate the significance of COVID-19 seroconversion is needed.

Liver transplant in a recently COVID-19 positive child with hepatoblastoma.

We describe the successful pediatric liver transplant for unresectable hepatoblastoma in a 4-year-old male with COVID-19 prior to transplant. The first negative NP swab was documented 1 month after initial diagnosis, when SARS-CoV-2 antibodies were also detected. The patient was actively listed for liver transplant after completing four blocks of a SIOPEL-4 based regimen due to his PRETEXT IV disease which remained unresectable. Following three additional negative NP swabs and resolution of symptoms for 4 weeks, he underwent a whole-organ pediatric liver transplant. COVID-19 positivity determined via NP swab SARS-CoV-2 real-time RT-PCR (Hologic Aptima SARS-CoV-2 RT-PCR assay). IgG and IgM total SARS- CoV-2 antibodies detected by Ortho Clinical Diagnostics VITROS® Immunodiagnostics Products Anti-SARS-CoV-2 Test. Patient received standard prednisone and tacrolimus-based immunosuppression without induction therapy following transplant. Post-transplant course was remarkable for neutropenia and thrombocytopenia, with discharge home on post-transplant day #11. Surveillance tests have remained negative with persistent SARS-CoV-2 IgG antibodies at 6 weeks after transplant. We describe one of the earliest, if not the first case of liver transplant following recent recovery from COVID-19 in a pediatric patient with a lethal malignant liver tumor. A better understanding of how to balance the risk profile of transplant in the setting of COVID-19 with disease progression if transplant is not performed is needed. We followed existing ASTS guidelines to document clearance of the viral infection and resolution of symptoms before transplant. This case highlights that pediatric liver transplantation can be safely performed upon clearance of COVID-19.

The pediatric solid organ transplant experience with COVID-19: An initial multi-center, multi-organ case series.

The clinical course of COVID-19 in pediatric solid organ transplant recipients remains ambiguous. Though preliminary experiences with adult transplant recipients have been published, literature centered on the pediatric population is limited. We herein report a multi-center, multi-organ cohort analysis of COVID-19-positive transplant recipients ≤ 18 years at time of transplant. Data were collected via institutions' respective electronic medical record systems. Local review boards approved this cross-institutional study. Among 5 transplant centers, 26 patients (62% male) were reviewed with a median age of 8 years. Six were heart recipients, 8 kidney, 10 liver, and 2 lung. Presenting symptoms included cough (n = 12 (46%)), fever (n = 9 (35%)), dry/sore throat (n = 3 (12%)), rhinorrhea (n = 3 (12%)), anosmia (n = 2 (8%)), chest pain (n = 2 (8%)), diarrhea (n = 2 (8%)), dyspnea (n = 1 (4%)), and headache (n = 1 (4%)). Six patients (23%) were asymptomatic. No patient required supplemental oxygen, intubation, or ECMO. Eight patients (31%) were hospitalized at time of diagnosis, 3 of whom were already admitted for unrelated problems. Post-transplant immunosuppression was reduced for only 2 patients (8%). All symptomatic patients recovered within 7 days. Our multi-institutional experience suggests the prognoses of pediatric transplant recipients infected with COVID-19 may mirror those of immunocompetent children, with infrequent hospitalization and minimal treatment, if any, required.