Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge

Table 1 Morbidity and mortality in pediatric surgical patients in the pandemic era

Ref.	Journal	Patient number	SARS-CoV-2 test	Disease	Treatment	Outcome	Study details
Place R et al[14]	JAMA Network Open 2020; 3: e2027948	90	N/A	CAA: 35CAA + abscess: 8	OT: 35; Abscess drainage with IA: 8	Successful	Retrospective study. The authors noted increased number of CAA compared with the same period in 2019
Kvasnovsky CL et al[15]	J Pediatr Surg 2020(Epub head of print)	55	Positive: 3 (without symptoms)	NOT: 25 (2 with CAA); OT: 30 (CAA: 13, Simple AA:17)	NOT: 25 pts (3 CAA); OT: 30 (13 CAA); 1 patient SARS-CoV-2+: OT; 2 patients SARS-CoV-2+: NOT	Successful	Retrospective study. 45.5% of all patients: NOT protocol to minimize operative resources; The majority of children (78.2%) did not meet previous criteria for non-admissions comparable to pre- SARS-CoV-2 era
Gerall CD et al[16]	J Pediatr Surg 2020 (Epub head of print)	89 (41: pre SARS-CoV-2 era, 48: SARS-CoV-2)	Positive: 4 (excluded from the study)	UAA and CAA	NOT: Antibiotics 3 in the pre- SARS-CoV-2 era vs 7 during pandemic; OT: 33 in the pre- SARS-CoV-2 era vs 23 during pandemic	Successful	Retrospective study. It compares children’s’ symptoms and complications in pro- vs SARS-CoV-2 era. Patients in SARS-CoV-2 era: -Duration of symptoms: longer; -Increased number of imaging findings for perforation, increased LOS, increased time until resolution of symptoms.
Snapiri O et al[17]	Acta Pediatr 2020; 109: 1672-1676	7	N/A	CAA (perforated, abscess)	OT: 4; NOT: 4 (abscess drainage)	Successful	Retrospective study. Delayed diagnosis: Insufficient initial evaluation, telemedicine: 3, parental concerns)
Fisher JC et al[18]	Ann Surg 2020 (Epub head of print)	57 patients SARS-CoV-2 era vs control: 1292	Positive: 11/28	CAA in the SARS-CoV-2 era: 45% vs 27% in the control group	OT: UAA: 30; CAA: 20; NOT: 7	Successful	Retrospective study. Comparison of clinical characteristics of children vs pre- SARS-CoV-2 era. Main findings: Higher duration of symptoms and perforation rates in the SARS-CoV-2 era. No differences between perforation rates and LOS among positive or negative SARS-CoV-2 children.
La Pergola F et al[19]	Front Pediatr 2020; 8: 600320	86 vs 309 in the pre- SARS-CoV-2 era	Positive: 3	UAA: 59; CAA: 27	N/A	Successful	Retrospective study. COVID-19 era vs previously (2017-2019); -No differences: in the prevalence of the AA, duration of symptoms and CAA
Raffaele A et al[20]	Br J Surg 2020; 107: e529-e530	14	Positive: None	UCC: 7; CAA: 7l	OT: 13/14; NOT: 1 (abscess drainage)	Successful	Retrospective study. -Delayed presentation in the ED vs previous years, delayed admission to OT due to COVID-19 test preoperatively
Montalva L et al[21]	Pediatr Surg Int 2020; 36: 1397-1406	108 (69 during lockdown)	Positive: 3	UAA: 24; CAA: 84	OT: UAA and CAA with peritonitis:94; CAA with abscess: 14 (drainage or medical treated)	Successful	Retrospective cohort study. The authors found increased cases of AA during the period of lockdown compared to pre-lockdown era. LOS, complication rates, re-admissions and peritoneal abscesses similar
Bellini T et al[22]	Acta Pediatr 2021 (Epub head of print)	27 in the SARS-CoV-2-era vs 75 control group	Positive: None	UAA: 14; CAA: 13 vs UAA: 50; CAA: 25	N/A	Successful	Retrospective study. CAA cases significantly more when compared with previous 3 yr due to delayed admissions (P = 0.004)
Zampieri N et al[23]	Minerva Pediatr 2020;	N/A	N/A	N/A	N/A	N/A	Retrospective study. The authors found decreased number cases of AA during lockdown vs post-lockdown period (P < 0.05) possibly due to the less exposure to co-factors
Velayos M et al[24]	Ann Pediatr (Barc) 2020; 93: 118-122	Pre- SARS-CoV-2-era: 41; Post- SARS-CoV-2: 25	Positive: 1	CAA: -pre- SARS-CoV-2: 3; -post- SARS-CoV-2: 8	OT: All patients	Successful	Retrospective study. Increased number of CAA in SARS-CoV-2 era compared to pre- SARS-CoV-2 era due to delayed diagnosis (P = 0.019), LOS increased in the CAA SARS-CoV-2 group
Malhotra A et al[25]	Pediatr Inf Dis J 2021; 40: e49-e55	10	Positive: 10	CAA+MIS-C-: 5; UAA: 5	OT: 8; NOT: 2	Successful	Retrospective study. CAA associated with MIS-C
Cai et al[26]	Front Pediatr 2020;8: 1-9	5	Positive: 5	1 patient: CAA + MIS-C	OT	Successful	Retrospective study. CAA associated with MIS-C
Schäfer FM et al[27]	Front Pediatr 2021; 9: 683607	514	N/A	CAA
Zvizdic Z et al[28]	J Pediatr Surg 2021; 56: 196-200	6	Positive: None	AA	OT	Successful	Letter to the Editor. Decreased admissions of AA compared to pre- SARS-CoV-2 era. Hypothesis: Correlation with decreased exposure to microbes due to lockdown
Lishman J et al[29]	J Pediatr Infect Dis 2020; 39: e472-e473	4	Positive: 4	UAA: 4; CAA: 2; MIS-C: 3	OT: 3	Successful	Case series. AA with MIS-C
Meyer JS et al[30]	J Pediatr Surg Case Rep 2021; 64: 101734	4	Positive: All	UAA: 2; CAA: 2	OT: 4	Successful	Case series. Possible association of SARS-CoV-2 with AA
Lee-Archer P et al[31]	J Pediatr Child Health 2020; 56: 1313-1314	48	N/A	UAA: 25; CAA: 23	OT	Successful	Brief communication. Increased number of CAA compared to previous years (2014-2019), parental concerns
Wang H et al[32]	Chin J Pediatr Surg 2020; 41: 299-302	1	Positive	UAA +; pneumonia	OT		Case report. UUA associated with pneumonia of the right lung
Harwood R[33]	J Surg Case Rep 2020; 9: 1-3	2	Positive: 1	CAA + MIS-C	OT	Successful	Case report. CAA associated with MIS-C
Shahbaznejad L[34]	BMC Pediatrics 2020; 513	10	Positive: 10	1 patient: UAA with MIS-C	OT	Successful	Case report. UAA associated with MIS-C
Alsuwallem AB et al[35]	Cureus 2020; 12: e8677	1	Positive	CAA	OT	Successful	Case report. CAA associated with COVID-19 Infection
Mehl SC et al[36]	Pediatr Infect Dis J 2021	1	Positive	NEC	NOT	Successful	Case report. Full term neonate with NEC secondary to SARS-CoV-2 infection
Rohani P et al[37]	J Pediatr Surg Case Rep 2021; 61: 101667	1	Positive	NEC	NOT	Successful	Case report. Gastrointestinal SARS-CoV-2 manifestation
Moazzam Z et al[38]	J Pediatr Surg Case Reports 2020; 59:101533	1	Positive	Intussusception	Pneumatic reduction	Successful	Case report. Gastrointestinal manifestation of SARS-CoV-2
Rajalakshmi L et al[39]	Indian J Pract Pediatr 2020; 22:236	1	Positive	Intussusception	Pneumatic reduction	Successful	Case report. Gastrointestinal manifestation of SARS-CoV-2
Martinez-Castañoi[40]	Pediatr Emerg Care 2020;36: e368	1	Positive	Intussusception	Hydrostatic reduction	Successful	Case report. Gastrointestinal manifestation of COVID-19
Makrinioti H et al[41]	J Pediatric Infect Dis Soc 2020; 9: 504-506	2	Positive: 2	Intussusception; Intussusception + malrotation	Pneumatic reduction; Surgical reduction + ladd procedure	Death; Successful	Case reports. Fatal gastrointestinal manifestation of SARS-CoV-2; Gastrointestinal manifestation of SARS-CoV-2
Bazuaye-Ekhuyasi EA et al[42]	Emerg Radiol 2020; 27: 761-764	1	Positive	Intussusception	Hydrostatic reduction	Successful	Case report. Gastrointestinal manifestation of SARS-CoV-2
Guerrón N et al[43]	Global Pediatr Health 2021; 8: 1-3	1	Positive	Intussusception	Hydrostatic reduction	Successful	Case report. Gastrrointestinal manifestation of COVID-19
Osorno JF et al[44]	Global Pediatr Health 2021; 8: 1-3	1	Positive	Intussusception (delayed presentation)	Laparotomy	Successful	Case report. Gastrrointestinal manifestation of COVID-19
Kawalec AM[45]	Burns 2020; 46: 1713-1714	Increased admissions in ED compared to previous year	N/A	Increased TBSA burns, house fire burns and PICU admissions vs previous year	Outpatient care, hospitalization, PICU	N/A	Retrospective study. Need for a family plan during pandemic
Demicran M[46]	Burns 2020 (Epub ahead of print)	Increased admissions and hospitalizations compared to previous year	N/A	Increased TBSA burns, increased all kinds of burns	Outpatient care, hospitalization	N/A	Retrospective study. Burn care material must be ready
Sethuraman U[47]	Burns 2020 (Epub head of print)	Increased admissions in ED vs all visits	N/A	Increased TBSA	Outpatient care, hospitalization, PICU	1 death	Retrospective study. Parents should keep children away from hot liquids and surfaces
Pelizzo G et al[48]	Healthcare 2021; 9: 551	84 (pandemic era: 52previous pre-pandemic period: 32)	Positive: 1	TBSA < 10%: 32; 10%-15%: 11; > 15% >: 9	34/52: Discharge; 18/52: Burn Service Area; (10/18: Ward; 8/18: PICU)	Successful	Retrospective study. A higher number of admissions during pandemic was noticed compared to the same period in the previous year. An appropriate planned service and care ensure a safe and feasible hospitalization without risks of infections and major complications
Marino-Mateo L et al[49]	Actas UrolEsp 2020; 44: 659-654	45	Positive: 0	Pelviureteric junction obstruction, spina bifida, lithiasis, hypospadias	49 interventions	Successful	Retrospective study. A stratification of the urological based on the different phases of pandemic and EAU was conducted
Cesaro S et al[50]	Pediatr Blood Cancer 2020; 67: e8466	247	Positives: 10	Solid tumors, leukemia	Ceased chemotherapy and radiation for 12-26 d	Successful	Retrospective study. Mild or asymptomatic patients with positive tests may continue therapy
Hrusak O et al[51]	Eur J Cancer 2020;132: 11-16	200	Positives: 9	Hepatoblastoma: 2; Wilms tumor: 1; Ewing’s sarcoma: 1; osteosarcoma: 1; cervical rhabdoid: 1; ALL: 1	Antibiotics and/or hydroxychoroquine, lopinavir, ritonavir	Successful	Retrospective study. Children on anticancer therapy may have mild or asymptomatic course of infection with SARS-CoV-2. In this case anticancer treatment should not be delayed or postponed
Madhusiidhan PP et al[52]	Pediatr Blood Cancer 2020; e28843	578	Positive: 98; No symptoms: 73	Neuroblastoma: 5,Solid tumor: 16; Others: 77	Mechanical; ventilation: 7; Supplemental oxygen: 25; SARS-CoV-2 direct treatment: 98	Successful: 94; Death: 4	Multi-institutional cohort study. Low morbidity and mortality among oncologic patients but higher than in general pediatrics. Significant impact of pandemic: Delay in therapy in 67% of positive patients; Overall delays: Chemotherapy 54%, surgery 46%, transplant 30%

CAA: Complicated acute appendicitis; OT: Operative treatment; IA: Interval appendectomy; NOT: Non-operative treatment; AA: Acute appendicitis; UAA: Uncomplicated acute appendicitis; LOS: Length of hospital stay; MIS-C: Multisystem inflammatory syndrome in children; ED: Emergency department; NEC: Necrotizing enterocolitis; TBSA: Total body surface area; ALL: Acute lymphoblastic leukemia; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; COVID-19: Coronavirus disease 2019; PICU: Pediatric intensive care unit.