COVID-19 Related Abnormalities in the Hematologic Characteristics among Inpatient Children. Results of the PICNIC Registry

S. Tehseen¹, J. Robinson², S. Williams³, L. Lieberman⁴, PICNIC Paediatric Investigator Collaborative Network on Infections in Canada

¹Saskatchewan Health Authority, Saskatoon, Canada, ²Department of Pediatrics. University of Alberta, Edmonton, Canada, ³Division of Hematology Oncology, Hospital for Sick Children, Toronto, Canada, ⁴University of Toronto, UHN and Affiliated Hospitals, Toronto, Canada

Abstract Number: PB0183

Meeting: ISTH 2021 Congress

Theme: COVID and Coagulation » COVID and Coagulation, Clinical

Background: Hematologic complications, including thrombosis, are well described in adults with COVID-19. Information regarding pediatric hematologic complications is limited.

Aims: Describe the hematologic complications of pediatric inpatients with COVID-19

Methods: An international, multi-center retrospective registry was created in June 2020 describing the clinical spectrum of COVID-19 hospitalized children. Information collected included: demographics, comorbidities, presentation, multi-system inflammatory syndrome (MIS-C) diagnosis, investigations, management and outcomes. Hematologic variables: were bleeding, signs of disseminated intravascular coagulation (DIC) and thrombosis or bleeding. Bleeding and MIS-C were defined per WHO criteria. DIC diagnosis was based on clinical judgement. Information was collected in Redcap and data analyzed using SAS.
Categorical data was reported as frequencies and proportions, continuous variables as means with standard deviations, or medians with interquartile range (IQRs) if data were skewed.

Results: 295 children were included and 104/295 (35%) had MISC. 107 (36.3%) children were admitted for alternate diagnosis with associated COVID-19 infection. 2 children (0.6%) developed thrombosis. 1 had an internal jugular vein thrombus and the other had extensive thromboembolism including pulmonary embolus (PE). 1 patient developed both PE and gastrointestinal (GI) hemorrhage. 5 children (1.7%) experienced bleeding where 4 had epistaxis and/or GI hemorrhage and 1 had pulmonary hemorrhage. 2 patients had DIC with bleeding. 4 children required blood products for management of hemorrhage. Rates of thrombosis and bleeding were similar between MIS-C and other COVID-19 patients. 117 (40%) children received prophylactic anti-coagulation (22 [7.4%] MIS-C patients) based on hospital specific policies. 5 (1.7%) deaths occurred in the cohort; all unrelated to COVID-19 associated hematologic complications.

Table 1: Demographics, clinical and laboratory features of inpatient children with COVID-19 and MISC

All (N =295)

MIS-C (N =104)

Covid-19 infection (N =191)

Demographics
Age (years): Median (IQR)
Female gender N (%) F

4 (IQR: 1-9)
128(43%)

5 (IQR: 2-8)
51(49%)

3 (IQR: 0-10)
77 (40%)

Co-morbid disorders

Cancer
Thrombophilia
Bleeding disorder
Immunodeficiency
CHD
Chronic lung disease
Sickle cell
End stage renal Disease
Hypertension
Obesity

109 (37%)

12(4%)
2(0.6%)
2(0.6%)
10(3%)
6(2 %)
4 (1.2%)
1 (0.3%)
2 (0.6%)
5 (1.7%)
15 (5%)

0
1(0.9%)
0
0
0
0
0
0
0
3 (3%)

12 (6.2%)
1 (0.6%)
2(1%)
10 (5%)
6 (3%)
4 (2%)
1(0.6%)
2 (1%)
5 (2.6%)
12 (6.2%)

Clinical hematologic complications N (Risk Factors: anatomic site)

Thrombosis only

Bleeding only

DIC with bleeding

Thrombosis and bleeding

8 (2.7%)

1 (APS: RLE DVT, PE)
0

1 (Sepsis: GI bleed)
1 (CVL, Obesity: PE and GI bleed)

1 (CVL: IJV clot)

3 (thrombocytopenia, MAS, CHD: Epistaxis, lung and GI bleed)
1 (AML, sepsis: Epistaxis)
0

Hematologic parameters
Median (IQR)
Hemoglobin g/dl
Platelets x 10⁹/L

PTT (sec)
Fibrinogen g/dl
D-Dimer ug/l

103 (IQR: 90-120)
241 (IQR: 154-342)

43 (IQR: 38-46)
6 (IQR: 4.9-6.8)
2660 (IQR: 1200-4001)

97 (IQR: 88-107)
463 (IQR: 345-655)

42.5 (IQR: 39-45)
6.1(IQR: 5-7)
2710 (IQR: 1120-4001)

112 (IQR: 92-127) *
340 (IQR: 230-433)*

44 (IQR: 32-47)
5.1 (IQR: 4.5-6.4)
1530 (IQR: 1220-3535)

Patients with significant hematologic lab abnormalities N(%)

Hemoglobin ≤ 70 g/dl
Platelets ≤ 50 x 10⁹/L
Platelets ≤ 10 x 10⁹/L
Fibrinogen≤1 g/dl
PTT ≥ 55 secs
Platelets≥450 x 10⁹ /L
Fibrinogen ≥ 5 g/dl
Abnormal D-Dimer

19 (6.4%)
15 (5%)
2 (0.6%)
2 (0.6%)
1 (0.3%)
92 (31%)
42 (14%)
99 (33%)

4 (4%)
2 (2%)
0
0
0
53 (51%)
36 (35%)
74 (71%)

15 (8%)
13 (7%)
2 (1%)
2 (1%)
1 (0.5%)
39 (20%)
6 (3%)
25 (13%)

Prophylactic anti-coagulation
N (%)

117(40%)

22 (21%)

50 (26%)

Cause of Death N (Risk Factors)
COVID related respiratory failure ±Sepsis

COVID related cardiac and respiratory dysfunction

5 (1.7%)

4 (developmental delay, CLD, malignancy)

1 (Renal failure with reflux disease of kidney)

5 (2.5%)

Demographics, clinical and laboratory features of inpatient children with COVID-19 and MISC
MIS-C: Multi system inflammatory syndrome in children. DIC: Disseminated intravascular coagulation. PE: Pulmonary Embolism, RLE: Right lower extremity DVT: Deep venous thrombosis, APS: Anti-phospholipid antibody syndrome, IJV: Internal jugular vein. Sepsis: Bacterial or fungal infection with DIC, MAS: Macrophage activation syndrome, CHD: hemodynamically significant congenital heart disease, CVL: Central venous line, ARDS: Acute respiratory distress syndrome, CLD: Chronic Lung Disease, AML: Acute Myeloid leukemia
*assumes significance at p-value > 0.05. Patients with MIS-C had a higher median age and platelet count with a lower hemoglobin compared to children without MIS-C.

Conclusions: This registry describes COVID-19 related hematologic complications in a large multi-center pediatric cohort. The frequency of these complications is low and related to underlying comorbidities in children. Ongoing research is crucial to understand covid-associated hematological challenges in children and to determine the indications of prophylactic anti-coagulation.

To cite this abstract in AMA style:

Tehseen S, Robinson J, Williams S, Lieberman L, PICNIC Paediatric Investigator Collaborative Network on Infections in Canada . COVID-19 Related Abnormalities in the Hematologic Characteristics among Inpatient Children. Results of the PICNIC Registry [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/covid-19-related-abnormalities-in-the-hematologic-characteristics-among-inpatient-children-results-of-the-picnic-registry/. Accessed May 16, 2022.

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