Journal of Tropical Pediatrics, 2021, 00, 1–9

doi: 10.1093/tropej/fmab025
Original Paper

Clinical and Epidemiological Characteristics of

Paediatric Patients Diagnosed with COVID-19
in a Tertiary Hospital in Mexico City

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Mercedes Macias-Parra MD, PDI,1 Sofia Fortes-Gutierrez MD, PDI,2
Nancy Aguilar-Gomez MD, PDI,2 Luisa Diaz-Garcia M.Sc., PhD.Sc.,3
Francisco Otero-Mendoza MD, PDI,2 Eduardo Arias de la
Garza MD, PDI,2 Javier Ordo~nez-Ortega MD, PDI,2 Debora
Palacios-Reyes MD, PDI,2 Irma Virginia Diaz-Jimenez MD, PDI,2
Alejandro Serrano-Sierra MD, PDI,4 Luis Xochihua-Dı́az
MD, PDI,2 and Patricia Saltigeral-Simental MD, PDI1
1
Medical Director, Instituto Nacional de Pediatrı́a, National Pediatrics Institute, Insurgentes Cuicuilco, Coyoacán, Mexico City, CP 04530, Mexico
2
Pediatric Infectious Disease Department, National Pediatrics Institute, Mexico City, Mexico
3
Research and Methodology Department, National Pediatrics Institute, Mexico City, Mexico
4
National Pediatrics Institute, Mexico City, Mexico
Correspondence: Patricia Saltigeral-Simental, Instituto Nacional de Pediatrı́a, National Pediatrics Institute, Av. Insurgentes Sur 3700,
Insurgentes Cuicuilco, Coyoacán, Mexico City, CP 04530, Mexico. Tel: þ52 551 084 0900. E-mail <drapatysaltigerals@hotmail.com>.

ABSTRACT
COVID-19 affects the paediatric population less frequently than adults. A retrospective study was
performed in a tertiary paediatric hospital in Mexico City in children <18 years of age who were
hospitalized with a positive reverse transcription-polymerase chain reaction for SARS-CoV-2.
Included in the study were 86 patients with a median age of 10 years old (IQR 2.6–14.3 years), who
were classified in three groups: previously healthy, with chronic disease and immunosuppressed
patients. The principal signs and symptoms were fever (81%), cough (51%) and headache (35%). A
total of 20 patients (23%) required management in the paediatric intensive care unit (PICU) and
17% needed mechanical ventilation for an average of 12.7 days (IQR 2–29 days). There was no stat-
istically significant difference between the three clinical classification groups in those patients admit-
ted to the PICU, most of which were previously healthy patients. The mortality rate was 5% (four
patients). Given that the paediatric population is susceptible to infection, potential transmitters and
to clinical presentations with variable degrees of severity, it is important to continue reinforcing so-
cial distancing measures.

K E Y W O R D S : COVID-19, paediatrics, clinical–epidemiological characteristics, comorbidities

C The Author(s) [2021]. Published by Oxford University Press. All rights reserved.
V
For permissions, please email: journals.permissions@oup.com  1
2  Factors Associated with Nipple Lesions in Puerperae
INTRODUCTION
At the end of 2019, a novel coronavirus was identified as
the cause of pneumonia in a group of patients in
Wuhan, Hubei Province, China. It quickly propagated,
causing an epidemic throughout China, followed by a
growing number of cases in other countries. In February
of 2020, the World Health Organization (WHO)
determined that it was a new type of beta-coronavirus
and called this new entity coronavirus disease 2019
(COVID-19). On 11 March 2020, the WHO declared
the new disease a worldwide pandemic [1]. The first
case was detected in Mexico on 27 February 2020 and
by 24 March, local transmission was identified. To 18
April 2021, the SARS-CoV-2 virus has infected
>122 367 676 people worldwide, with >2 million
deaths registered, and a global mortality rate of 2.3%.
Mexico has been one of the countries most heavily hit,
with 2 376 875 registered cases and 217 216 deaths in
the general population to 18 April 2021 (a mortality rate
of 9%) [2].
The pediatric population is affected less frequently
than adults. Studies performed in different countries
have demonstrated that children represent 1–8% of la-
boratory-confirmed cases [3].In the series from China
[728 cases confirmed by real-time reverse transcription-
polymerase chain reaction (RT-PCR) SARS CoV-2],
14% of the children were asymptomatic, 43% presented
with mild disease, 41% moderate, 2.3% severe and 0.4%
were in critical condition [4].Multinational studies that
included 582 cases were done in Europe, in which
8% of the patients required paediatric intensive care
unit (PICU) management. In the USA, the CDC
(n ¼ 2500) reported that 80% manifested mild to
moderate disease, 0.5–2% were admitted to the
PICU, and the <1-year age group was the one most
hospitalized and admitted for therapy [5].
In Mexico, 111 386 cases of COVID-19 have been
reported in paediatric patients to 18 April 2021, with a
total of 422 deaths [2]. The clinical spectrum of
COVID-19 varies from self-limiting disease of the upper
respiratory airways to serious pneumonia with acute re-
spiratory distress syndrome, in addition to other manifes-
tations, such as multisystem inflammatory syndrome in
children (MIS-C). The objective of this study is to de-
scribe the epidemiological, clinical and molecular charac-
teristics and laboratory and imaging findings of 86
patients hospitalized with a diagnosis of COVID-19 in a
children’s hospital in Mexico City.
Study design
A cross-sectional study was done in a tertiary child-
ren’s hospital in Mexico City from 1 April to
28 September 2020.
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METHODOLOGY
The study included a total of 86 hospitalized patients
under 18 years of age with a clinical presentation sug-
gestive of COVID-19 and a confirmed infection by
SARS-CoV-2 detected by RT-PCR. Three groups
were identified by means of the patients’ underlying
pathologies and classified as: previously healthy
patients, those with chronic disease (heart diseases,
neurological disorders, genetic syndromes, nephrop-
athy, obesity, asthma and chronic pneumonia) and
immunosuppressed patients (primary immunodefi-
ciency, aplastic anaemia, sickle-cell anaemia, leukae-
mia, lymphoma, solid tumours, and solid organ and
haematopoietic stem cell post-transplant patients).
Finally, patients who met the CDC-defined criteria
were classified with MIS-C or with Kawasaki disease,
based on clinical criteria. Since this was a retrospect-
ive study, no informed consent was required [3].
Study variables
Initial information was obtained from the standar-
dized case report format and from clinical e-files.
Clinical data registered in the initial examination
were fever (>38 C for 1 h or a random measure-
ment of 38.3 C), cough, conjunctivitis, rhinorrhoea,
odynophagia, dyspnoea, chest pain, abdominal pain,
diarrhoea, vomiting, convulsive seizures, myalgia,
arthralgia, fatigue, exanthema, adenopathy, irritabil-
ity, headache, anosmia and dysgeusia. Laboratory
studies included haemoglobin (g/dl), total WBC
(mm3), neutrophils (mm3), lymphocytes (mm3),
and platelets (103 Ul); inflammatory markers: C-re-
active protein (md/dl), ferritin (ng/ml), procalcito-
nin (PCT, ng/ml), fibrinogen (mg/dl) and D-dimer
(lg/ml). Imaging studies included a chest X-ray and,
in patients with pulmonary involvement, a high-reso-
lution CT (HRCT) was performed. The reported

results included admission to the PICU, mechanical
ventilation, treatment with inotropic agents, steroids,
anticoagulants, gamma globulin and death.
SARS-CoV-2 molecular biology
Samples were taken via nasopharyngeal swab (two
per patient) and/or bronchoalveolar lavage in intu-
bated patients. Samples were shipped in universal
virus media. Nucleic acid extraction was performed
with the GeneFinderTM COVID-19 PLUS RealAmp
kit that is utilized to qualitatively detect the SARS-
CoV-2 virus through RT-PCR, from RNA extracted
from respiratory samples [6, 7].The assay is compat-
ible in combination with the ELITe InGeniusV in-
strument. The RT-PCR is used to confirm the
presence of RdRp, E and N genes. The cycle thresh-
old value (Ct value) for positivity is <43 [5, 8].
Statistical analysis
Categorical variables are presented in frequencies.
The Mantel–Haenszel X2 test was used to contrast
them. Continuous variables are presented in averages
and standard deviations and, since they meet the
normality criteria to contrast by averages, the factor
ANOVA test was used. SPSS version 22.0 (IBMV
R
SPSSV) was used as the statistical program.
20
18
16
14
Numbero fo cases
12
10
0
April
Number of cases 8 17
Fig. 1. Epidemic curve of paediatric hospital admissions during COVID-19 pandemic in a tertiary children’s hospital.
Factors Associated with Nipple Lesions in Puerperae  3
RESULTS
From 1 April to 28 September 2020, 86 cases of hos-
pitalized children were identified as PCR positive for
SARS-CoV-2. The first case was identified on 16
April 2020. Figure 1 shows the epidemic curve (rep-
resented in months), the greatest number of positive
cases being reported in June. The epidemiological
contact history was documented in 42 cases and the
parents were the principal source of infection in 39%
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of the cases.
Patient characteristics
Table 1 is a summary of the demographic and clinic-
R al characteristics of patients classified by underlying
pathology. The average age was 121.5 months (IQR
31.7–172). The greatest number of cases was found
in the >12 years age group with 35 patients (40%),
followed by the 60 days to 5 years age group with 24
(33%) patients and three (3.5%) <60 days old, all
previously healthy. The 23.35% of the patients
required PICU management, of which 60% had an
underlying disease, predominantly immunosuppres-
sion (25%). The male : female ratio was 1.04 : 1. In
84% of the patients, the infection was community-
acquired.
R
The most frequent clinical manifestations were
fever (81%), followed by cough (51%) and headache
May June July August September
20 16 15 10
Month of admission
4  Factors Associated with Nipple Lesions in Puerperae

TABLE 1. Demographic characteristics and ICU admission of children with COVID-19

Total Previously Chronic Immunosuppressed
cohort, n (%) healthy, n (%) diseases, n (%) and oncological, n (%)
86 (100) 33 (38.4) 25 (29.1) 28 (32.6)

Agea
<60 days 3 (3.5) 3 (100) 0 (0) 0 (0)
60 days to <5 years 28 (32.6) 16 (57.1) 8 (28.6) 4 (14.3)
5 to <12 years 21 (24.4) 6 (28.6) 6 (28.6) 9 (32.1)

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>12 years 34 (39.5) 8 (23.5) 11 (42.8) 15 (53.5)
Sex
Male 44 (51.2) 15 (45.5) 13 (52) 16 (57.1)
Female 42 (48.8) 18 (54.5) 12 (48) 12 (42.9)
Acquisitiona
Community 76 (84.4) 33 (100) 23 (92) 20 (71.4)
In-hospital 10 (11.6) 0 2 (8) 8 (28.6)
Admission to paediatric intensive care unit 20(23.3) 8(24.2) 5(20) 7(25)
a
Mantel–Haenszel X2 tests with p < 0.05.

TABLE 2. Signs and symptoms in paediatric patients with COVID-19, by category

Total Previously Chronic Immunosuppressed and
cohort, n (%) healthy, n (%) diseases, n (%) oncological, n (%)
86 (100) 33 (38.4) 25 (29.1) 28 (32.6)

Conjunctivitis 12 (14) 6 (18.2) 2 (8) 4 (14)

Cough 44 (51) 15 (45.6) 14 (56) 15 (53.6)
Fever 70 (81) 24 (72.3) 21 (84) 26 (92.9)
Rhinorrhoea 26 (30.3) 14 (42.3) 6 (24) 6 (21)
Odynophagia 19 (21.1) 8 (24.2) 4 (16) 7 (25)
Dyspnoea 21 (24.4) 7 (21.2) 9 (36) 5 (17.9)
Chest pain 3 (3.5) 1 (3.1) 2 (8) 0
Abdominal pain 22 (25.6) 8 (24.2) 7 (28) 7 (25)
Diarrhoea 6 (7) 6 (18.2) 2 (8) 1 (3.6)
Vomitinga 16 (18.6) 8 (24.2) 7 (28) 1 (3.6)
Seizures 6 (7) 1 (3) 4 (16) 1 (3.6)
Myalgiaa 21 (24.4) 10 (30.3) 4 (16) 7 (25)
Arthralgia 15 (17.4) 6 (18.2) 2 (8) 7 (25)
Fatigue 16 (18.6) 6 (18.2) 6 (24) 4 (14.3)
Rash 9 (10.5) 6 (18.2) 2 (8) 1 (3.6)
Adenopathya 9 (10.5) 6 (18.2) 3 (12) 0
Irritabilitya 21 (24.4) 13 (39.4) 7 (28) 1 (3.6)
Headache 30 (34.8) 10 (24.2) 8 (20) 12 (42.9)
a
Mantel–Haenszel X2 tests with p < 0.
 Factors Associated with Nipple Lesions in Puerperae  5

(35%), with no significant differences between the

(n ¼ 19) 156 473 6(135 553)

different groups. Gastrointestinal symptoms were

(n ¼ 12) 33 467 6(4752)

(n ¼ 11) 52.966(113.53)
(n ¼ 14) 54.586(199.86)
(n ¼ 19) 7236 6(4962)
(n ¼ 19) 4963 6(4794)
(n ¼ 19) 1684 6(1400)

(n ¼ 9) 16.55 6(14.33)
abdominal pain (25.6%), vomiting (19%) and diar-

(n ¼ 16) 4196(118)
rhoea (7%). Neurological symptoms included head-
ache (35%), irritability (24%) and convulsive
seizures (7%). The greatest frequency of vomiting,

Severe, m6SD
myalgia, lymphadenopathy and irritability (p < 0.05)
was in the previously healthy patient group (see
Table 2). Other presentations such as MIS-C and

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Kawaski disease were reported in 4% of patients.
There were no cases of anosmia and dysgeusia.

(n ¼ 20) 182 400 6(116 327)

(n ¼ 9) 91.066(262.13)
(n ¼ 20) 3885 6(6214)
(n ¼ 20) 86106(6142)
(n ¼ 20) 37906(3462)

(n ¼ 9) 15.306(14.03)
Laboratory results

(n ¼ 9) 19576(1984)
(n ¼ 11) 3.886(6.15)

(n ¼ 10) 4046(169)
Laboratory test results (mean and SD) classified by
severity is shown in Table 3. There was no statistic-

Moderate, m6SD
al difference in severity found between the different
groups. Non-statistically different C-reactive pro-
tein, procalcitonin, ferritin and fibrinogen all
showed the highest values in patients with severe
disease. A viral co-infection was documented in 12
TABLE 3. Laboratory findings in paediatric patients with COVID-19, by severity

patients (14%): parainfluenza type 3 in five

(n ¼ 46) 278 341 6(559 367)

(n ¼ 46) 8863 6(6009.59)
patients, followed by rhinovirus/enterovirus in four

(n ¼ 18) 34.116(113.78)
(n ¼ 18) 10.876(12.58)
(n ¼ 46) 5463 6(5206)
and adenovirus in three. No bacterial co-infection (n ¼ 46) 2658 6(3529)

(n ¼ 14) 13546(2174)
(n ¼ 13) 1.326(2.88)

(n ¼ 17) 3506(121)
was documented.

Imaging studies
Mild, m 6SD

Chest X-rays were taken in 80 patients, of which

37% were normal and 48 (55%) had some kind of
alteration. The most frequent findings were: 29
(34%) with interstitial infiltrates, 11 (13%) with
(n ¼ 85) 228 525 6(421 496)

multiple foci, 3 (3%) with ground glass opacities,

consolidation in 3 cases (3%), 1 (1%) with pleural
(n ¼ 41) 53.606(186.60)
(n ¼ 36) 13.406(13.25)
(n ¼ 35) 18.666(66.11)
(n ¼ 85) 4957 6(4756)
(n ¼ 85) 2729 6(4049)

effusion and 1 (1%) with air entrapment. The most

(n ¼ 85) 84406(5795)

(n ¼ 35) 22336(3304)
(n ¼ 43) 3886(133)

frequent finding was interstitial infiltrates in 29

Total cohort, m6SD

patients, with no statistical difference between the

three groups. An HRCT of the Lung was done in
17 patients, the main findings being: ground glass
in 7 patients (41%), multiple foci in 2 (11%), pleu-
ral effusion in 2 (11%) and normal findings in 6
patients (35%, Table 4).
A total of 20 patients (23%) were admitted to
Neutrophils (cells/ml)
Lymphocytes (cells/ml)

Fibrinogen (mg/dl)
Leukocytes (cells/ml)

Platelets (cells/ml)

the PICU—of which 8 (40%) were previously

D-dimer (lg/ml)
Ferritin (ng/ml)

healthy, 7 (35%) were haemato-oncological

PCT (ng/ml)
PCR (mg/dl)

patients and 2 (10%) were obese—for an average

stay of 12.2 days (2–30 days), 17% requiring mech-
anical ventilation for an average of 12.7 days (2–
29 days), 20% requiring inotropic agents and 21%
6  Factors Associated with Nipple Lesions in Puerperae

TABLE 4. Radiological and tomographic findings in paediatric patients with COVID-19

Total cohort, n (%) 86 Radiological findings

Chest X-ray
Normal 80 (93)
Interstitial 32 (40)
Infiltrates
Multiple foci 29 (36.2)
Ground glass 11 (12.7)

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Consolidation 3 (3.7) Chest X-ray with poorly defined, predominantly para-
Pleural 3 (3.7) hilar and bibasilar bilateral opacity, with air broncho-
Effusion 1 (1.25) gram, which translates to alveolar occupancy.
Air entrapment 1 (1.25)
Chest CT 17 (19)
Ground glass 7 (41)
Normal 6 (35.2)
Multiple foci 2 (11.7)
Pleural effusion 2 (11.7)

Simple chest CT showing bilateral ground glass pat-

tern, with consolidations predominantly in the left
lobe.

anticoagulation. Four (5%) of the patients admitted
to the PICU died, of which one was previously
healthy, two were obese and one was a post bone
marrow transplant patient.
DISCUSSION
The clinical–epidemiological characteristics of chil-
dren infected with the SARS-CoV-2 virus are
described in this study. Children and adolescents are
less affected by COVID-19 than adults [5, 9]. The
CDC reported (n ¼ 2572) confirmed cases of
COVID-19 in persons under 18 years of age, which
represents 1.7% of the total number of reported
cases [7]. The Australian Health Protection Principal
Committee (AHPPC) reported that children repre-
sent 4% of cases, related to exposure factors (less
going out in public compared with adults) and host
factors (less ACE2 receptors) [10, 11]. Paediatric
patients have a less severe clinical manifestation and
lower hospitalization rate. In the Wuhan series, up to
20% of children and adolescents were reported as
asymptomatic [4, 12].
Age at presentation was similar to that reported
in other paediatric series, which contrasts with the
Italian series in which the average age was 2.3 years
(IQR 0–17 years old) [13].
In this study, most cases occurred in the >12 age
group (39.5%) and the <60 days age group, the
three cases were previously healthy, did not require
admission to the PICU and did not manifest severe
disease, contrary to what was reported in Europe, in
which patients under one month of age ran the
greatest risk of admission to the PICU [10]. In
China, the <1 month old group had a greater pro-
portion of severe patients (10.6%), suggesting they
were more vulnerable to presenting with severe in-
fection [4, 12]. This difference might be due to the
fact these series had a greater number of patients
<1 month of age. In the New York (NY) study,
patients <60 days old represented 29% of patients,
36% presenting with mild and 29% moderate disease.
No patient in this age group manifested severe dis-
ease, similar to what was found in this review [14].
With respect to age and gender, the results were very
similar to what is reported in the literature, with no

significant differences between the clinical classifica-
tion groups.
The most frequent clinical manifestations were
fever (81%) followed by cough (51%), similar to
what is reported in worldwide paediatric series: Italy,
fever 82%, cough 49%; CDC, fever 56%, cough 54%;
NY, fever 88%, cough 49%; Europe, fever 56%, and
cough 54%; Mexico (HIMFG) fever 60%, cough
49% [10, 14–17]. One-fourth of patients presented
gastrointestinal symptoms (abdominal pain 26%,
vomiting 19%, diarrhoea 7%), some without co-re-
spiratory symptoms, similar to what is reported in
other series from Europe (22%) and NY (40%) [10,
15]. In regards to neurological manifestations, the
prevalent symptom was headache (35%), similar to
that reported by other authors like Mundeep et al.
[15] and Götzinger et al. [10]. Convulsive seizures
were predominant in the group of patients with
chronic diseases, similar to that reported in Italy,
where this symptom was prevalent in patients with a
prior history of epilepsy [14].
In this review, 54% of patients manifested mild,
23% moderate, 13% severe and 9% critical disease.
In the severe group, we found that patients with
chronic diseases presented the greatest number of
critical cases (20%), compared with the other clinical
classification groups (previously healthy 3% and im-
munosuppressed 7%). The European study reports
that the presence of a prior medical condition is
associated with a greater risk of admission to the
PICU [10].
In this study 23% of patients were admitted to
the PICU, compared with 35% in the NY study,
which also only included hospitalized patients [15],
contrary to what was reported in China (Wuhan),
6%, and the USA in general, 10%, where ICU admis-
sion could be secondary to including outpatients,
and both series had a larger study population [4, 13,
16]. No statistical difference was found between the
three clinical classification groups amongst PICU-
admitted patients, nor in those requiring mechanical
ventilation or inotropic agents, which is relevant be-
cause the comorbidities in this review did not repre-
sent a greater risk of admission to intensive care. It
would be important in future studies to examine in-
dividual underlying pathologies in the population to
assess if, independently, they present a greater risk
Factors Associated with Nipple Lesions in Puerperae  7
for PICU admission, the use of inotropic agents and
mechanical ventilation. In the European study,
patients with chronic pulmonary disease, asthma and
pulmonary dysplasia had a greater risk of PICU ad-
mission (p ¼ 0.012), followed by oncological
patients [10].
MIS-C was initially described in the UK, then in
America. In the French/Swiss series (n ¼ 35) an
average age of 10 years old was reported, with a
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PCR-SARS-CoV-2 positivity rate of 34%, serologically
positive 86%; all patients were admitted to the PICU.
The UK reported 58 patients with an average age of
9, with 26% PCR SARS-CoV-2 positive and 78%
serologically positive, 50% of the patients required
PICU management [18, 19]. These findings are simi-
lar to what was reported in this study, in which 19%
presented MIS-C, 4% Kawasaki disease, an average
age of 10 years old and 75% admitted to the PICU.
Only PCR SARS-CoV-2 positive patients were
included, compared with other studies. It is important
to consider that no PCR positive for SARS-CoV-2
finding is required to establish a diagnosis of MIS-C.
Globally, it is reported that some parameters for a
CBC can be suggestive of SARS-CoV-2 infection:
leukopenia is present in 15%, lymphopenia 90% and
thrombocytopenia, as well as markers that suggest a
poor prognosis, like D-dimer elevation, C-reactive
protein, IL-6 and ferritin [16, 20, 21]. A study in
adults done in Mexico City reported that patients
who were admitted to the ICU suggested a more in-
tense inflammatory response, a more severe pro-
thrombotic state and greater frequency of liver and
heart involvement [1]. In this review, we found no
significant differences in lab test results due to sever-
ity (CDC) or clinical classification, possibly due to
the different underlying pathologies included in this
study.
Treatment for patients with COVID-19 is contro-
versial and support measures are fundamental [22].
Antibiotics are administered if there is a suspicion of
a bacterial co-infection and these must be re-eval-
uated once culture test results are in [23–26]. The
only antiviral agent approved by the FDA is
Remdesivir, in addition to monoclonal antibodies.
The use of steroids has been associated with less
mortality in adults; studies in children are on-going
[27, 28]. The benefits of other treatments
8  Factors Associated with Nipple Lesions in Puerperae
(Tocilizumab, Anakinra, Gamma globulin) are not
conclusive [29]. A children’s hospital in Mexico City
applied a comprehensive treatment: antibiotics ini-
tially in 54%, systemic steroid, 28%, Gamma globu-
lin, 25%, anticoagulants, 21% and Tocilizumab in a
single patient.
In this review, mortality was 5%, contrary to what
is reported in the series from the UK and China,
which was 0.9% [4, 30].
Limitations
It is important to point out that one of the study lim-
itations is that only hospitalized patients were
included. Therefore, the study population probably
represents children in the more severe spectrum of
the disease. Ultimately, since this is a cross-sectional
study, we believe that bias due to time, memory and
poor classification might affect study data. However,
this is an opportunity to create a cohort for follow-up.
CONCLUSIONS
Despite the fact that most of the patients included in
this series had a chronic disease or were immunosup-
pressed, a greater number of previously healthy
patients were admitted to intensive care. Mortality
was greater than that reported in other series, mostly
in patients with some type of comorbidity. It is im-
portant to continue to reinforce social distancing
measures because children are susceptible to infec-
tion, potential transmitters and to clinical presenta-
tions with variable degrees of severity.
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