Gastrointestinal Symptoms Linked to Severe COVID-19 Outcomes in Pediatric Patients


GI symptoms manifest in children with COVID-19 more than they do in adult patients.

Children with SARS-CoV-2 infections that present with gastrointestinal symptoms more frequently have longer hospital stays and more severe outcomes.

A team, led by Andrea Lo Vecchio, MD, PhD, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, identified the clinical, radiological, and histopathologic characteristics of pediatric patients with COVID-19 with severe gastrointestinal manifestations to better forecast factors associated with severe outcomes.


Throughout the COVID-19 pandemic, severe gastrointestinal symptoms has been common in children with COVID-19, but it is unknown what the frequency and clinical outcomes of these gastrointestinal symptoms are and why pediatric patients are impacted more than adults.

There have also been studies that show 15% of pediatric patients with COVID-19 present with diarrhea, particularly in infancy. Vomiting (10%) or abdominal pain (8%) also have a higher frequency in school-aged children.

“A better knowledge of the factors associated with severe GI manifestations, as well as an increased awareness of their clinical course and outcome, may provide supporting information to practitioners working either in the setting of the emergency department or in primary care,” the authors wrote.

Italian Data

In the multicenter retrospective cohort study, the investigators examined 685 inpatient and outpatient pediatric patients with acute SARS-CoV-2 infections between Feb. 25, 2020 and Jan. 20, 2021 in primary care or hospitals in Italy as part of the COVID-19 Registry of the Italian Society of Pediatric Infectious Diseases. Of the patients included in the study, 56.4% (n = 386) were male and the median age of the entire patient population was 7.3 years.

Each infection was confirmed by a real-time reverse-transcriptase-polymerase chain reaction on nasopharyngeal swab or fulfilling the US Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children (MIS-C).

The investigators defined severe gastrointestinal manifestations by a medical and/or radiological diagnosis of acute abdomen, appendicitis (complicated or not by perforation and/or peritonitis), intussusception, pancreatitis, abdominal fluid collection, and diffuse adenomesenteritis requiring surgical consultation.

The investigators sought main outcomes of these manifestations during or within 4-6 weeks following SARS-CoV-2 infections and estimated odds ratios and confidence intervals associated with severe outcomes using logistic regression.

Gastrointestinal Symptoms

A total of 628 (91.7%) pediatric patients were diagnosed with infections, while 57 (8.3%) patients were diagnosed with MIS-C. In addition, 37.5% (n = 257) of patients exhibited gastrointestinal symptoms during the disease course.

However, the investigators found gastrointestinal symptoms was linked to a higher rate of hospitalization (OR, 2.64; 95% CI, 1.89-3.69), as well as intensive care unit admission (OR, 3.90; 95% CI, 1.98-7.68).

Mild or moderate gastrointestinal involvement was found in 74.7% (n = 192) children, characterized by diarrhea (n = 107; 55.71%) in most cases, vomiting (n = 58; 30.2%), or abdominal pain (n = 39; 20.3%). Also, 77.2% (n = 44) of the patients with MIS-C showed evidence of gastrointestinal involvement.

There were 65 (9.5%) pediatric patients included in the study that showed severe gastrointestinal involvement including disseminated adenomesenteritis (39.6%), appendicitis (33.5%), abdominal fluid collection (21.3%), pancreatitis (6.9%), or intussusception (4.6%).

Of this group, 41.5% (n = 27) underwent surgery.

There were other trends found in the data.

For example, age (5-10 years: OR, 8.33; 95% CI, 2.62-26.5; >10 years: OR, 6.37; 95% CI, 2.12-19.1, compared with preschool-age), abdominal pain (adjusted OR [aOR], 34.5; 95% CI, 10.1-118), lymphopenia (aOR, 8.93; 95% CI, 3.03-26.3), or MIS-C (aOR, 6.28; 95% CI, 1.92-20.5) were all associated with severe gastrointestinal manifestations.

The investigators also found diarrhea was linked to a higher rate of adenomesenteritis (aOR, 3.13; 95% CI, 1.08-9.12) or abdominal fluid collection (aOR, 3.22; 95% CI, 1.03-10.0). This group had a longer median hospital stay (n = 10; IQR, 6-18 days) and an increased risk of intensive care unit admission (n = 19; 29.2%) compared to patients with mild to moderate (n = 9; 4.7%) or no (n = 13; 3.0%) gastrointestinal symptoms (P < .001).

“In this multicenter cohort study of Italian children with SARS-CoV-2 infection or MIS-C, 9.5% of the children had severe GI involvement, frequently associated with MIS-C,” the authors wrote. “These findings suggest that prompt identification may improve the management of serious complications.”

The study, “Factors Associated With Severe Gastrointestinal Diagnoses in Children With SARS-CoV-2 Infection or Multisystem Inflammatory Syndrome,” was published online in JAMA Network Open.

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