Last week, when the state first released data on coronavirus cases by hospital, the numbers seemed almost predictable. Many large hospitals had well above 100 patients; smaller community ones had dozens.
But one number was striking: Boston Children’s Hospital had seven patients admitted with confirmed or suspected cases of coronavirus, including three in the intensive care unit. The number of COVID-19-positive admissions has since climbed to 13, with three in the ICU as of Sunday.
In a pandemic perceived as largely sparing the very young from serious illness, a growing number of children infected with COVID-19 in Massachusetts have become so severely ill that they have needed hospitalization — sometimes even ventilators. The sickest of these patients have typically had underlying health conditions.
One such child was a 16-year-old girl admitted last month at Boston Children’s Hospital in serious condition. Staff immediately suspected coronavirus. Her blood oxygen was low, plummeting briefly to 52 percent — a startlingly dangerous level.
She was also autistic, and couldn’t tolerate a mask on her face to deliver oxygen, so a therapist positioned a tube a few inches away. Still, her oxygen remained too low.
A team swiftly brought the girl, feverish and suffering from pneumonia, up to the intensive care unit. Doctors tried a BiPAP machine to deliver oxygen, then intubated her with a ventilator. Seventy-two hours after admission, the test results came in: a confirmed case of COVID-19.
It was a phenomenon that is still relatively unusual: a child descending into life-threatening illness from the coronavirus.
“They have the full range of severity of illness that one sees in adults,” said Dr. Michael Agus, division chief of medical critical care at Boston Children’s Hospital. “However it is a far, far smaller number.”
According to state data, of the 38,077 confirmed coronavirus cases in Massachusetts as of Sunday, only 899 — or 2.4 percent — involved people age 19 or younger. Across the United States, fewer children than adults have suffered such symptoms as cough, fever, or shortness of breath, and relatively few children have been hospitalized with COVID-19, according to a recent Centers for Disease Control report on the coronavirus disease among children.
Three children with COVID-19 are reported to have died in the United States, according to the April 6 CDC study. No children with COVID-19 have died in Massachusetts, according to state data.
“Children are intriguingly resistant to developing critical illness,” said Dr. Jeffrey Burns, chief of critical care at Boston Children’s Hospital. “Why do they get infected apparently as easily as anyone else, but why are they resistant to critical illness?” It’s still a mystery, he said.
Still, rare severe cases do occur. Boston Children’s Hospital had admitted a total of 15 children with COVID-19 by last Thursday, as well as four patients age 18 or older, according to a spokesperson. Most of the children have been school-age to teenage, and the youngest is 7 weeks old. At any given time, the hospital has two to four COVID-19 patients in the ICU, and one or two on a ventilator, Agus said.
“All of the patients in the sicker range have had underlying conditions,” he noted. Most commonly their immune systems have been compromised because of a genetic problem, an acquired disorder, or a medication for some other illness, or obesity may be a factor.
The 16-year-old girl had been receiving chemotherapy because of a genetic disease, so her immune system was suppressed, said her mother, who requested anonymity out of concern for her family’s privacy. The girl was initially treated at a hospital north of Boston, but transferred to Boston Children’s Hospital, where her specialists were based.
When those specialists heard about her condition, they immediately recommended that chemotherapy be suspended to help protect her immune system. “I was so shocked about how they reacted so fast,” said the mother, who praised the hospital’s doctors, nurses, and social workers for their care.
The girl improved enough to be taken off the ventilator and even to eat some of her favorite foods — pizza and strawberries. After about three weeks, she walked out. “She is happy,” said her mother. “She’s loving being outside of the hospital right now.”
Some serious coronavirus cases involving children that might otherwise be handled elsewhere in Massachusetts are now coming to Boston Children’s Hospital, Burns said, as other pediatric intensive care units in the state have been converted to help care for adult COVID-19 patients, either in whole or in part.
As such, Boston Children’s is on the front lines of pediatric COVID-19 care. While Massachusetts General Hospital has two COVID-19 inpatients under the age of 18, other major Massachusetts hospitals told the Globe they did not have children hospitalized for the coronavirus, or declined to offer data.
Coronavirus treatment at the hospital varies on a case-by-case basis. “I’m not sure you’d find two patients who are treated exactly the same,” said Agus. When using ventilators, they can manipulate the pressure and air flow to adjust for the size of the child. They are also trying to use more non-invasive ventilation, applying it through a mask or using a high-flow nasal cannula, to avoid putting in a breathing tube and sedating a patient.
Therapies have included hydroxychloroquine, remdesivir, and tocilizumab, said Agus — three medicines that are now in US clinical trials for COVID-19 treatment. And the hospital has joined a trial for convalescent serum, which involves plasma donated by recovered COVID-19 patients who have antibodies to the virus.
As with adult patients, the illness can take sudden and unpredictable shifts with children. On more than one occasion, Agus said, the hospital has seen children who had gotten dramatically better, and then they “suddenly flip and begin to get significantly worse.”
“We had our eye open for it,” he said. “But until you see it, one’s medical instinct is that when a patient begins to get better, they continue to get better.”
Amid the pandemic, Boston Children’s Hospital has had a major advantage: a biocontainment unit originally created to deal with Ebola, another infectious disease, several years ago. At the beginning of March, the team sprang into action. Members trained doctors and nurses on protocols for personal protective equipment, and they used simulations to practice treating coronavirus patients.
“The biggest lesson for me is that preparation for the incredibly unlikely is always worth doing,” said Agus, who is co-medical director of the biocontainment unit. “The team has enabled this 400-bed hospital to mold itself and reimagine itself into an infectious disease hospital. Making that transition is not something that 99 percent of hospitals thought they would ever have to do.”