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Background and Objectives: Neurological involvement associated with SARS-CoV-2 infection is increasingly recognized. However, the specific characteristics and prevalence in pediatric patients remain unclear. The objective of this study was to describe the neurological involvement in a multinational cohort of hospitalized pediatric patients with SARS-CoV-2. Methods: This was a multicenter observational study of children Results: One-hundred forty-seven (21%) of 697 hospitalized children with SARS-CoV-2 infection had neurological signs/symptoms. Headache (n = 103), encephalopathy (n = 28), and seizures (n = 30) were the most reported. Neurological signs/symptoms were significantly associated with ICU admission (OR: 1.71, 95% CI: 1.15–2.55; p = 0.008), satisfaction of MIS-C criteria (OR: 3.71, 95% CI: 2.46–5.59; p < 0.001), fever during hospitalization (OR: 2.15, 95% CI: 1.46–3.15; p < 0.001), and gastrointestinal involvement (OR: 2.31, 95% CI: 1.58–3.40; p < 0.001). Non-headache neurological manifestations were significantly associated with ICU admission (OR: 1.92, 95% CI: 1.08–3.42; p = 0.026), underlying neurological disorders (OR: 2.98, 95% CI: 1.49–5.97, p = 0.002), and a history of fever prior to hospital admission (OR: 2.76, 95% CI: 1.58–4.82; p < 0.001). Discussion: In this study, approximately 21% of hospitalized children with SARS-CoV-2 infection had neurological signs/symptoms. Future studies should focus on pathogenesis and long-term outcomes in these children.

SARS-CoV-2 infection can lead to multisystem inflammatory syndrome in children (MIS-C). We sought to investigate risk factors for admission to the intensive care unit (ICU) and explored changes in disease severity over time.We obtained data from chart reviews of children younger than 18 years with confirmed or probable MIS-C who were admitted to 15 hospitals in Canada, Iran and Costa Rica between Mar. 1, 2020, and Mar. 7, 2021. Using multivariable analyses, we evaluated whether admission date and other characteristics were associated with ICU admission or cardiac involvement.Of 232 children with MIS-C (median age 5.8 yr), 130 (56.0%) were male and 50 (21.6%) had comorbidities. Seventy-three (31.5%) patients were admitted to the ICU but none died. We observed an increased risk of ICU admission among children aged 13-17 years (adjusted risk difference 27.7%, 95% confidence interval [CI] 8.3% to 47.2%), those aged 6-12 years (adjusted risk difference 25.2%, 95% CI 13.6% to 36.9%) or those with initial ferritin levels greater than 500 μg/L (adjusted risk difference 18.4%, 95% CI 5.6% to 31.3%). Children admitted to hospital after Oct. 31, 2020, had numerically higher rates of ICU admission (adjusted risk difference 12.3%, 95% CI -0.3% to 25.0%) and significantly higher rates of cardiac involvement (adjusted risk difference 30.9%, 95% CI 17.3% to 44.4%). At Canadian sites, the risk of ICU admission was significantly higher for children admitted to hospital between December 2020 and March 2021 than those admitted between March and May 2020 (adjusted risk difference 25.3%, 95% CI 6.5% to 44.0%).We observed that age and higher ferritin levels were associated with more severe MIS-C. We observed greater severity of MIS-C later in the study period. Whether emerging SARS-CoV-2 variants pose different risks of severe MIS-C needs to be determined.

Background: To date, there are only sporadic reports of acute abdomen and appendicitis in children with coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C). Methods: Children 17 years of age or younger assessed in 5 Latin American countries with a diagnosis of microbiologically confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and children fulfilling MIS-C definition were included. For children with acute abdomen, we investigate main radiologic patterns, surgical treatment and intraoperative findings, outcomes. Findings: One-thousand ten children were enrolled. Forty-two children (4.2%) had a clinical diagnosis of acute abdomen. Four (9.5%) were diagnosed with MIS-C and did not undergo surgery. The remaining 38 children (3.8%) underwent abdominal surgery due to suspected appendicitis, 34 of them (89.7%) had an intraoperative diagnosis of acute appendicitis (AA), while 4 of them had nonsurgical findings. Eight children died (0.8%), none of them being diagnosed with appendicitis. Children with AA were significantly older than those without (P < 0.0001). Children with complicated appendicitis had more frequently fever (85.7% vs. 60%), intestinal distension on the abdominal radiograph (7.1% vs. none), leukocytosis (85.7% vs. 40%) and high levels of C-reactive protein (35.7% vs. 5%), although differences were not statistically significant. Conclusions: Our study showed that children may present with acute abdomen during COVID-19 or MIS-C, which is not always associated with intraoperative findings of appendicitis, particularly in case of MIS-C. Further studies are needed to better characterize children with acute abdomen during COVID-19 or MIS-C, to avoid delay in diagnosis of surgical conditions and at the same time, minimize unnecessary surgical approaches.

BACKGROUND: Recently, hoarseness affecting the supraglottic structure has been reported in Kawasaki Disease. The objective of this study was to characterize the frequency of hoarseness in acute KD patients in Latin America. METHODS: We used prospective data from the multinational REKAMLATINA Network (Red de Enfermedad de Kawasaki en America Latina) a total of 865 patients from 20 countries were enrolled during the 3-year study period. Data on hoarseness was available in 858 (99.2%) patients. The clinical and laboratory characteristics between hoarse and non-hoarse KD were compared. RESULTS: Hoarseness was documented in 100 (11.6%) patients. Hoarse patients were younger compared to KD without hoarseness (median age 18 vs. 26 months; p=0.002) and presented with a lower hemoglobin (10.7g/dL vs 11.3g/dL; p= 0.040) and hematocrit levels (32% vs 33%, p=0.048) . CONCLUSIONS: Hoarseness was found to be prevalent as a presenting sign of acute KD in younger children. Anemia may indicate the presence of active inflammation.

Objective We aimed to evaluate the clinical and epidemiological behavior of influenza type A versus type B and analyze if there was any correlation or differences between the characteristics of both groups. Methods An observational, retrospective, descriptive, and population-based study based of children who were hospitalized at the only national pediatric hospital of Costa Rica from January 1, 2010 to December 31, 2018 and had a confirmed influenza virus infection. Results 336 patients were analyzed. Mean age was 35,6 ± 36,7 months (3,0 ± 3,1 years). The only significant variables at 25% in relation to influenza type A or B virus were: sex, month of diagnosis, fever, vomiting, cough, use of antibiotics and admission to the PICU. The hospitalization rate at our hospital increased between the months of October to December, with a higher percentage of cases in November and December, which reveals that the "real peak" in our population begins between 3 to 4 months after the end of the vaccination campaign. Patients with influenza A virus had a 2.5 times greater risk of being admitted to the PICU. Mortality rate was 0.6% and 0% among influenza A and B children, respectively. Conclusions Variables in which a causality was found with type A or B virus were: admission to the PICU, month of diagnosis, and cough. However, influenza B clinical behavior continues to be unpredictable.

Aim: This study aims to assess rates of antibiotic prescriptions and its determinants in in children with COVID-19 or Multisystem Inflammatory Syndrome (MIS-C). Methods: Children

The objective of this study was to describe the clinical course and outcomes in children with technology dependence (TD) hospitalized with SARS-CoV-2 infection.Seventeen pediatric hospitals (15 Canadian and one each in Iran and Costa Rica) included children up to 17 years of age admitted February 1, 2020, through May 31, 2021, with detection of SARS-CoV-2. For those with TD, data were collected on demographics, clinical course and outcome.Of 691 children entered in the database, 42 (6%) had TD of which 22 had feeding tube dependence only, 9 were on supplemental oxygen only, 3 had feeding tube dependence and were on supplemental oxygen, 2 had a tracheostomy but were not ventilated, 4 were on non-invasive ventilation, and 2 were on mechanical ventilation prior to admission. Three of 42 had incidental SARS-CoV-2 infection. Two with end-stage underlying conditions were transitioned to comfort care and died. Sixteen (43%) of the remaining 37 cases required increased respiratory support from baseline due to COVID-19 while 21 (57%) did not. All survivors were discharged home.Children with TD appear to have an increased risk of COVID-19 hospitalization. However, in the absence of end-stage chronic conditions, all survived to discharge.

Coagulopathy and thrombosis associated with SARS-CoV-2 infection are well defined in hospitalized adults and leads to adverse outcomes. Pediatric studies are limited.An international multicentered (n = 15) retrospective registry collected information on the clinical manifestations of SARS-CoV-2 and multisystem inflammatory syndrome (MIS-C) in hospitalized children from February 1, 2020 through May 31, 2021. This sub-study focused on coagulopathy. Study variables included patient demographics, comorbidities, clinical presentation, hospital course, laboratory parameters, management, and outcomes.Nine hundred eighty-five children were enrolled, of which 915 (93%) had clinical information available; 385 (42%) had symptomatic SARS-CoV-2 infection, 288 had MIS-C (31.4%), and 242 (26.4%) had SARS-CoV-2 identified incidentally. Ten children (1%) experienced thrombosis, 16 (1.7%) experienced hemorrhage, and two (0.2%) experienced both thrombosis and hemorrhage. Significantly prevalent prothrombotic comorbidities included congenital heart disease (p-value .007), respiratory support (p-value .006), central venous catheter (CVC) (p = .04) in children with primary SARS-CoV-2 and in those with MIS-C included respiratory support (p-value .03), obesity (p-value .002), and cytokine storm (p = .012). Comorbidities prevalent in children with hemorrhage included age10 years (p = .04), CVC (p = .03) in children with primary SARS-CoV-2 infection and in those with MIS-C encompassed thrombocytopenia (p = .001) and cytokine storm (p = .02). Eleven patients died (1.2%), with no deaths attributed to thrombosis or hemorrhage.Thrombosis and hemorrhage are uncommon events in children with SARS-CoV-2; largely experienced by those with pre-existing comorbidities. Understanding the complete spectrum of coagulopathy in children with SARS-CoV-2 infection requires ongoing research.

Age is the most important determinant of COVID-19 severity. Infectious disease severity by age is typically J-shaped, with infants and the elderly carrying a high burden of disease. We report on the comparative disease severity between infants and older children in a multicenter retrospective cohort study of children 0 to 17 years old admitted for acute COVID-19 from February 2020 through May 2021 in 17 pediatric hospitals. We compare clinical and laboratory characteristics and estimate the association between age group and disease severity using ordinal logistic regression. We found that infants comprised one-third of cases, but were admitted for a shorter period (median 3 days IQR 2-5 versus 4 days IQR 2-7), had a lower likelihood to have an increased C-reactive protein, and had half the odds of older children of having severe or critical disease (OR 0.50 (95% confidence interval 0.32-0.78)). Conclusion: When compared to older children, there appeared to be a lower threshold to admit infants but their length of stay was shorter and they had lower odds than older children of progressing to severe or critical disease. What is Known: • A small proportion of children infected with SARS-CoV-2 require hospitalization for acute COVID-19 with a subgroup needing specialized intensive care to treat more severe disease. • For most infectious diseases including viral respiratory tract infections, disease severity by age is J-shaped, with infants having more severe disease compared to older children. What is New: • One-third of admitted children for acute COVID-19 during the first 14 months of the pandemic were infants. • Infants had half the odds of older children of having severe or critical disease.

ImportanceChildren are less likely than adults to have severe outcomes from SARS-CoV-2 infection and the corresponding risk factors are not well established.ObjectiveTo identify risk factors for severe disease in symptomatic children hospitalized for PCR-positive SARS-CoV-2 infection.DesignCohort study, enrollment from February 1, 2020 until May 31, 2021Setting15 children’s hospitals in Canada, Iran, and Costa RicaParticipantsPatients ExposuresVariables assessed for their association with disease severity included patient demographics, presence of comorbidities, clinical manifestations, laboratory parameters and chest imaging findings.Main Outcomes and MeasuresThe primary outcome was severe disease defined as a WHO COVID-19 clinical progression scale of ≥6, i.e., requirement of non-invasive ventilation, high flow nasal cannula, mechanical ventilation, vasopressors, or death. Multivariable logistic regression was used to evaluate factors associated with severe disease.ResultsWe identified 403 hospitalizations. Median age was 3.78 years (IQR 0.53-10.77). At least one comorbidity was present in 46.4% (187/403) and multiple comorbidities in 18.6% (75/403). Severe disease occurred in 33.8% (102/403). In multivariable analyses, presence of multiple comorbidities (adjusted odds ratio 2.24, 95% confidence interval 1.04-4.81), obesity (2.87, 1.19-6.93), neurological disorder (3.22, 1.37-7.56), anemia, and/or hemoglobinopathy (5.88, 1.30-26.46), shortness of breath (4.37, 2.08-9.16), bacterial and/or viral coinfections (2.26, 1.08-4.73), chest imaging compatible with COVID-19 (2.99, 1.51-5.92), neutrophilia (2.60, 1.35-5.02), and MIS-C diagnosis (3.86, 1.56-9.51) were independent risk factors for severity. Comorbidities, especially obesity (40.9% vs 3.9%, pConclusions and RelevancePediatric risk factors for severe SARS-CoV-2 infection vary according to age and can potentially guide vaccination programs and treatment approaches in children.Key pointsQuestionWhat are the risk factors for severe disease in children hospitalized for PCR-positive SARS-CoV-2 infection?FindingsIn this multinational cohort study of 403 children, multiple comorbidities, obesity, neurological disorder, anemia, and/or hemoglobinopathy, shortness of breath, bacterial and/or viral coinfections, chest imaging compatible with COVID-19, neutrophilia, and MIS-C diagnosis were independent risk factors for severity. The risk profile and presence of comorbidities differed between pediatric age groups, but age itself was not associated with severe outcomes.MeaningThese results can inform targeted treatment approaches and vaccine programs that focus on patient groups with the highest risk of severe outcomes.

ObjectiveTo identify risk factors for severe disease in children hospitalised for SARS-CoV-2 infection.DesignMulticentre retrospective cohort study.Setting18 hospitals in Canada, Iran and Costa Rica from 1 February 2020 to 31 May 2021.PatientsChildrenMain outcome measureSeverity on the WHO COVID-19 Clinical Progression Scale was used for ordinal logistic regression analyses.ResultsWe identified 403 hospitalisations. Median age was 3.78 years (IQR 0.53–10.77). At least one comorbidity was present in 46.4% (187/403) and multiple comorbidities in 18.6% (75/403). Eighty-one children (20.1%) met WHO criteria for PCR-positive MIS-C. Progression to WHO clinical scale score ≥6 occurred in 25.3% (102/403). In multivariable ordinal logistic regression analyses adjusted for age, chest imaging findings, laboratory-confirmed bacterial and/or viral coinfection, and MIS-C diagnosis, presence of a single (adjusted OR (aOR) 1.90, 95% CI 1.13 to 3.20) or multiple chronic comorbidities (aOR 2.12, 95% CI 1.19 to 3.79), obesity (aOR 3.42, 95% CI 1.76 to 6.66) and chromosomal disorders (aOR 4.47, 95% CI 1.25 to 16.01) were independent risk factors for severity. Age was not an independent risk factor, but different age-specific comorbidities were associated with more severe disease in age-stratified adjusted analyses: cardiac (aOR 2.90, 95% CI 1.11 to 7.56) and non-asthma pulmonary disorders (aOR 3.07, 95% CI 1.26 to 7.49) in childrenConclusionWe identified risk factors for disease severity among children hospitalised for PCR-positive SARS-CoV-2 infection. Comorbidities predisposing children to more severe disease may vary by age. These findings can potentially guide vaccination programmes and treatment approaches in children.

Background Kawasaki disease (KD) is an acute systemic vasculitis that predominantly affects patients younger than 5 years. In the absence of an available, affordable diagnostic test, detailed clinical history and physical examination are still fundamental to make a diagnosis. Methods We present five representative cases with KD-like presentations: systemic onset juvenile idiopathic arthritis, mycoplasma-induced rash and mucositis, staphylococcal scalded skin syndrome, BCGosis, and the recently described multisystemic inflammatory syndrome in children (MIS-C) associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus. Results Rash, fever, and laboratory markers of inflammation can be present in several childhood diseases that may mimic KD. Conclusion The term 'Kawasaki syndrome' instead of 'Kawasaki disease' may be more appropriate. Physicians should consider an alternative diagnosis that may mimic KD, particularly considering MIS-C during the present pandemic, as an aggressive diagnostic and therapeutic approach is needed.

Costa Rica is an upper middle-income country in Central America with a vigorous public health system. We have studied the number of cases, hospitalizations, and deaths due to pertussis from 1961 to 2018, in relation to vaccine coverage. Following the introduction of the fourth and fifth doses of DTP (booster doses) in 1973 there was a marked reduction of reported pertussis. In 2002 pertussis surveillance and laboratory diagnosis were improved. In 2007, Tdap post-partum immunization was introduced and then switched to intrapartum Tdap immunization in 2011. Of these two strategies post-partum vaccination seemed to have a greater effect in decreasing hospitalizations and deaths, nevertheless, since 2011 there has been only 4 infant deaths due to pertussis.

BACKGROUNDSARS-CoV-2 infection can lead to multisystem inflammatory syndrome in children (MIS-C). We investigated risk factors for severe disease and explored changes in severity over time.METHODSChildren up to 17 years of age admitted March 1, 2020 through March 7th, 2021 to 15 hospitals in Canada, Iran and Costa Rica with confirmed or probable MIS-C were included. Descriptive analysis and comparison by diagnostic criteria, country, and admission date was performed. Adjusted absolute average risks (AR) and risk differences (RD) were estimated for characteristics associated with ICU admission or cardiac involvement.RESULTSOf 232 cases (106 confirmed) with median age 5.8 years, 56% were male, and 22% had comorbidities. ICU admission occurred in 73 (31%) but none died. Median length of stay was 6 days (inter-quartile range 4-9). Children 6 to 12 years old had the highest AR for ICU admission (44%; 95% confidence interval [CI] 34-53). Initial ferritin greater than 500 mcg/L was associated with ICU admission. When comparing cases admitted up to October 31, 2020 to those admitted later, the AR for ICU admission increased from 25% (CI 17-33) to 37% (CI 29-46) and for cardiac involvement from 44% (CI 35-53) to 75% (CI 66-84). Risk estimates for ICU admission in the Canadian cohort demonstrated a higher risk in December 2020-March 2021 compared to March-May 2020 (RD 25%; 95%CI 7-44).INTERPRETATIONMIS-C occurred primarily in previously well children. Illness severity appeared to increase over time. Despite a high ICU admission incidence, most children were discharged within one week.

Bacillus Calmette-Guérin (BCG) local scar inflammatory reactions have been mostly associated with Kawasaki disease in children and less commonly with other viral infections (i.e., measles). BCG scar inflammation associated with or following vaccine administration has only been reported with the influenza vaccine. We describe the first reports in the literature of local BCG inflammation following two different available messenger ribonucleic acid (mRNA) anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) vaccines (mRNA-1273, and BNT162b2) in two young healthy physicians, one from Costa Rica, and another from the United States of America, with normal cell blood counts, flow cytometries, and negative for human immunodeficiency virus (HIV). In both cases, BCG scar inflammation appeared after 24 hours of vaccination of the second dose, without signs of reaction on the injection site, and resolved within four days. Dermoscopic findings in one case showed arborizing and comma-shaped vessels. Pharmacovigilance surveillance of BCG scar reactions following coronavirus disease 2019 (COVID-19) vaccines should be considered particularly in countries where BCG is part of their national immunization programs.

Resumen A pesar de que la tosferina (coqueluche) es una enfermedad prevenible por vacunas (EPV), la epidemiología latinoamericana muestra que hay persistencia de brotes en la región. Esta persistencia se debe, al menos en parte, a factores tales como la cobertura vacunal, la presencia de movimientos anti vacunas, la diversidad de los sistemas locales de vigilancia y la falta de una definición de caso unificada para la región. Dada la importancia de la tosferina en Latinoamérica y los cambios ocurridos en las recomendaciones para la vacunación, este manuscrito tiene como objetivo revisar los datos epidemiológicos y los cambios recientes en los calendarios de vacunación y su impacto sobre la enfermedad pediátrica por Bordetella pertussis en Latinoamérica. Los datos epidemiológicos más recientes muestran que entre regiones, países, y segmentos dentro de cada país hay heterogeneidad en la cobertura vacunal, con distintos rebrotes. Esfuerzos en la región han tratado de mejorar esta situación al introducir vacunas acelulares (aP), menos reactogénicas que las vacunas de células enteras (wP) en los calendarios vacunales. Además, algunos países han mejorado la definición de caso confirmado, al introducir la reacción de polimerasa en cadena (RPC) como criterio diagnóstico. En respuesta a las heterogeneidades de cada país y a la epidemiología actual de la región, un Comité de Expertos de la Sociedad Latinoamericana de Infectología Pediátrica (SLIPE) y la Asociación Latinoamericana de Pediatría (ALAPE) propone una definición unificada de caso y recomendaciones para mejorar la cobertura vacunal y reducir los brotes de tosferina en Latinoamérica.

BackgroundA cohort study was conducted to describe and compare the characteristics of SARS-CoV-2 infection in hospitalized children in three countries.MethodsThis was a retrospective cohort of consecutive children admitted to 15 hospitals (13 in Canada and one each in Iran and Costa Rica) up to November 16, 2020. Cases were included if they had SARS-CoV-2 infection or multi-system inflammatory syndrome in children (MIS-C) with molecular detection of SARS-CoV-2 or positive SARS-CoV-2 serology.ResultsOf 211 included cases (Canada N=95; Costa Rica N=84; Iran N=32), 103 (49%) had a presumptive diagnosis of COVID-19 or MIS-C at admission while 108 (51%) were admitted with other diagnoses. Twenty-one (10%) of 211 met criteria for MIS-C. Eighty-seven (41%) had comorbidities. Children admitted in Canada were older than those admitted to non-Canadian sites (median 4.1 versus 2.2 years; pConclusionsApproximately half of hospitalized children with confirmed SARS-CoV-2 infection or MIS-C were admitted with other suspected diagnoses. Disease severity was higher at non-Canadian sites. Neonates, children with comorbidities and those with chest radiographs compatible with COVID-19 were at increased risk for severe or critical COVID-19.Main pointsApproximately half of hospitalized children with laboratory confirmed MIS-C or SARS-CoV-2 infection were admitted with another primary diagnoses. The severity of disease was higher in the middle income countries (Costa Rica and Iran) than in Canada.

SummaryData from adult studies how that COVID-19 is more severe in men than women. However, no data are available for the pediatric population. For this reason, we performed this study aiming to understand if sex influenced disease severity and outcomes in a large cohort of latin-american children with COVID-19 and Multisystem Inflammatory Syndrome (MIS-C). We found that a higher percentage of male children developed MIS-C (8.9% vs 5% in females) and died (1.2% and 0.4% in females), although on multivariate adjusted analyses the only statistically significant difference was found in need of hospitalization, with females less frequently admitted compared with boys (25.6% vs 35.4%). This data are preliminary and need further independent studies to better assess the role of sex.

Despite significant progress in reaching some milestones of the United Nations Sustainable Development Goals, neonatal and early infant morbidity and mortality remain high, and maternal health remains suboptimal in many countries. Novel and improved preventative strategies with the potential to benefit pregnant women and their infants are needed, with maternal and neonatal immunization representing effective approaches. Experts from immunology, vaccinology, infectious diseases, clinicians, industry, public health, and vaccine-related social sciences convened at the 5th International Neonatal and Maternal Immunization Symposium (INMIS) in Vancouver, Canada, from 15 to 17 September 2019. We critically evaluated the lessons learned from recent clinical studies, presented cutting-edge scientific progress in maternal and neonatal immunology and vaccine development, and discussed maternal and neonatal immunization in the broader context of infectious disease epidemiology and public health. Focusing on practical aspects of research and implementation, we also discussed the safety, awareness, and perception of maternal immunization as an existing strategy to address the need to improve maternal and neonatal health worldwide. The symposium provided a comprehensive scientific and practical primer as well as an update for all those with an interest in maternal and neonatal infection, immunity, and vaccination. The summary presented here provides an update of the current status of progress in maternal and neonatal immunization., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: Knowledge about neurological manifestations of SARS-CoV-2 in children is limited. We describe neurological manifestations in an international cohort of hospitalized pediatric patients. Methods: This is a multi-national observational study involving tertiary healthcare institutions in Canada, Costa Rica and Iran. We included patients 1 day-18 years admitted for any medical reason February 1, 2020-January 31, 2021 with laboratory evidence of SARS-CoV-2 infection by RT-PCR or serological testing. Descriptive analyses and logistic regression were performed where appropriate using JASP version 0⋅13. Findings: 298 hospitalized children with confirmed SARS-CoV-2 infection (median age 3⋅9 years [IQR 0⋅6-10⋅1]) from Canada (n=152), Costa Rica (n=115) and Iran (n=31) were included. Fifty-one (17%) had neurological manifestations, of which headache (73%), seizures (23%) and altered mental status (6%) were most frequently seen. Children with neurological symptoms had equivalent rates of comorbidities overall but were more likely to have underlying chronic neurological conditions. Additionally, those with neurological symptoms were more likely to be admitted to the ICU (15/51 [29%] vs. 32/247 [13%]; p =0⋅0033) and had longer length of hospital stay (6 days [IQR 3-8] vs. 4 days [IQR 2-7]; p =0⋅0060). Abnormalities were found in all children with neurological manifestations who received neuroimaging (n=6). Neurological manifestations were seen in 19% of the Iranian cohort, 23% of the Costa Rican cohort, and 12% of the Canadian cohort. Country of residence Costa Rica (adjusted OR: 2⋅520, 95% CI: 1⋅325-4⋅791, p =0⋅005), ICU admission (adjusted OR: 2⋅678, 95% CI: 1⋅307-5⋅486, p =0⋅007) and number of acute SARS-CoV-2 infection symptoms (adjusted OR: 1⋅355, 95% CI: 1⋅232-1⋅491, p

BackgroundTo date, there are no comprehensive data on antibiotic use in children with COVID-19 and Multisystem Inflammatory Syndrome (MIS-C).MethodsMulticenter cohort study from 5 Latin American countries. Children 17 years of age or younger with microbiologically confirmed SARS-CoV-2 infection or fulfilling MIS-C definition were included. Antibiotic prescriptions were collected and factors associated with their use were calculated.Findings990 children were included, with a median age of 3 years (interquartile range 1–9). Of these, 69 (7.0%) were diagnosed with MIS-C. The prevalence of antibiotic use was 24.5% (n = 243). MIS-C with (OR = 45.48) or without (OR = 10.35) cardiac involvement, provision of intensive care (OR = 9.60), need for hospital care (OR = 6.87), pneumonia and/or ARDS detected through chest X-rays (OR = 4.40), administration of systemic corticosteroids (OR = 4.39), oxygen support, mechanical ventilation or CPAP (OR = 2.21), pyrexia (OR = 1.84), and female sex (OR = 1.50) were independently associated with increased use of antibiotics. On the contrary, lower respiratory tract infections without radiologic evidence of pneumonia/ARDS and not requiring respiratory support (OR = 0.34) were independently associated with decreased use of antibiotics. There was significant variation in antibiotic use across the hospitals.ConclusionsOur study showed a relatively high rate of antibiotic prescriptions in children with COVID-19 and in particular in those with severe disease or MIS-C. Importantly, we found a significant variation in reasons for prescriptions of antibiotics and type of chosen therapies, as well in hospital practices, highlighting current uncertainties and lack of guidelines for the recognition of bacterial infections in children with COVID-19. Prospective studies are needed to provide better evidence on the recognition and management of bacterial infections in COVID-19 children.What is knownCOVID-19 may worsen antibiotic prescription practicesWhat this newCOVID-19 and MIS-C children frequently received antibioticsThere was a wide variation in antibiotic prescriptions among institutions, highlighting the lack of practicle guidelines in the use of antibiotics in children with COVID-19

Resumen Antecedentes: La enfermedad de Kawasaki (EK) representa la principal causa de cardiopatía pediátrica adquirida en muchos países; sin embargo, hay pocos estudios publicados en Latinoamérica. Objetivo: Describir la epidemiología, los aspectos clínicos y el tratamiento de EK en niños en Panamá como parte del estudio de vigilancia de REKAMLATINA-2 en Latinoamérica. Pacientes y Métodos: Estudio retrospectivo, descriptivo, de pacientes internados con diagnóstico de EK, atendidos en tres hospitales pediátricos de Panamá del 1-enero-2009 al 31-diciembre-2013. Resultados: Se analizaron 111 pacientes, 61(54,9%) eran hombres. Todos fueron hospitalizados, siendo la media de hospitalización de 5,8 (4-7) días. La mediana de edad al ingreso fue de 28,9 (12-38) meses. Un 63,9% recibió antimicrobianos recientemente por otros posibles diagnósticos. Recibieron inmunoglobulina intravenosa (IGIV) 105 (94,6%) pacientes; de éstos, 10 (9,5%) fueron resistentes. Un 11,7% tuvo alteraciones cardiovasculares en el ECO inicial, de las cuales las lesiones coronarias se detectaron en 3 (2,9%) pacientes. Conclusiones: Los datos sugieren que EK en Panamá tiene una incidencia cercana a 2,05 x 100,000 bajo 15 años de edad y una frecuencia 2,6 veces mayor bajo 3 años de edad. Se observó un alto porcentaje de uso de antimicrobianos ambulatoriamente antes de la confirmación diagnóstica, lo cual sugiere reconocimiento tardío de EK en Panamá.

Although whooping cough is a vaccine-preventable disease (VPD), its epidemiologic characteristics in Latin America shows persistence of outbreaks in the region. This persistence is due, at least in part, to the presence of antivaccine movements, the diversity of the surveillance systems, and the lack of a uniform case definition for the region. Given the importance of whooping cough in Latin America and the changes in vaccine recommendations, this manuscript aims to review epidemiologic data and recent changes in the vaccination calendars and their impact on the pediatric disease by Bordetella pertussis in Latin America. Recent epidemiological data reveal that between regions, countries, and administrative units within each country there is a marked heterogeneity of vaccine coverage, with different outbreak patterns. Efforts in the region have tried to improve this situation by introducing acellular pertussis vaccines (aP) in the vaccine calendars, which are less reactogenic than whole-cell pertussis vaccines (wP). Moreover, some countries have improved the case definition. Some countries have implemented a confirmed case definition by introducing polymerase chain reaction (PCR) as a diagnostic criterion. As a response to the heterogeneities observed within and between countries and the regional epidemiologic profiles, a Steering Committee from the Latin American Society for Pediatric Infectiology (SLIPE) and the Latin American Association of Pediatrics (ALAPE) propose a unified case definition and recommendations to improve vaccine coverage and reduce the outbreaks of whooping cough in Latin America.

Resumen Antecedentes: La enfermedad de Kawasaki (EK) en lactantes bajo un año de edad es poco frecuente en la mayoría de los países. Este grupo de pacientes tienen mayor riesgo de desarrollar complicaciones cardiacas. Objetivo: Evaluar el comportamiento clínico, tratamiento empleado y pronóstico cardiaco en lactantes bajo un año de edad atendidos por EK en un hospital pediátrico de tercer nivel en la Ciudad de México. Pacientes y Métodos: Estudio retrospectivo, descriptivo, de pacientes con diagnóstico de EK desde agosto de 1995 a agosto de 2019. Se estudió la presentación clínica, los exámenes de laboratorio, el tratamiento administrado y el desarrollo de lesiones coronarias en pacientes bajo un año de edad y se comparó con pacientes mayores. Resultados: Se estudiaron 687 pacientes, 152 de ellos eran lactantes bajo un año de edad (22,1%). Hubo un mayor tiempo al diagnóstico de la EK en los lactantes menores, con un incremento de presentaciones clínicas incompletas; este grupo de pacientes desarrolló en forma más frecuente lesiones coronarias en comparación con los pacientes mayores y también tuvo un mayor porcentaje de aneurismas coronarios gigantes. Hubo dos fallecimientos en los lactantes menores, secundarios a infarto al miocardio. Conclusiones: El diagnóstico de EK en pacientes bajo un año de edad es un reto diagnóstico con presentaciones clínicas incompletas y mayor riesgo de desarrollar complicaciones cardiacas graves.

Kawasaki disease is an acute systemic vasculitis and is the leading cause of acquired cardiac disease in children. Among the ocular manifestations in these patients, bilateral non-suppurative conjunctival injection and uveitis are the most common. We describe a six-year-old Costa Rican girl with acute Kawasaki disease who developed severe bilateral conjunctival injection with subsequent bilateral subconjunctival hemorrhages. For her ocular involvement, she was treated expectantly, and after six weeks there was complete resolution. To our knowledge, this is the first report from Latin America and among the few in the literature of a child in whom severe bilateral subconjunctival hemorrhages occur as a manifestation of Kawasaki disease.