{"paper_id":"18ff0adb-ec76-4a57-8bff-26b2e452fdd8","body_text":"Comparative Analysis of Routine Blood Laboratory Tests in Multisystem Inflammatory Syndrome in Children (MIS-C) and Kawasaki Disease Among White and Black Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Analysis of Routine Blood Laboratory Tests in Multisystem Inflammatory Syndrome in Children (MIS-C) and Kawasaki Disease Among White and Black Children Namisha Khara, Luz A Padilla, Sabrina Chowdhury, Howard W Wiener, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8689314/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract To assess racial differences in disease presentation and blood laboratory parameters in improving diagnostic accuracy and management strategies for Kawasaki Disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C), a retrospective study was conducted at Children’s of Alabama. Patients with KD, admitted between January 2000 and January 2020 and those with MIS-C, between January 2021 and December 2022 were identified using the Children’s of Alabama hospital’s administrative database yielding 591 records. KD patients were defined using the American Heart Association (AHA) diagnostic criteria and MIS-C patients were defined based on CDC definition. Only patients with a parent-reported race of Black or White were included. All patients with the eight key blood laboratory parameters, Hematocrit, C-Reactive Protein (CRP), Aspartate Aminotransferase (AST), Alanine Transaminase (ALT), Creatinine, Sodium, Platelet count, and Erythrocyte Sedimentation Rate (ESR) at the acute phase of the disease were included in the study. Age specific range of clinical values were assessed to define abnormal measurements. Race-specific analysis was conducted using descriptive statistics (mean, median and standard deviation). A logistic regression model using sum of abnormal lab parameters was applied to distinguish MIS-C from KD within Black and White populations. MIS-C patients were older than KD cases across both racial groups (median age 10 years vs. 3.36 years). MIS-C showed significantly elevated inflammatory markers (CRP, AST, ALT) compared to KD, suggesting a heightened systemic inflammatory response. Kidney dysfunction (elevated creatinine) was more common in Black MIS-C patients, indicating possible racial disparities in disease severity. The odds of developing MIS-C increased by 2.9 times with the total number of lab tests below normal range, whereas an increase in the number of lab tests above normal range decreased MIS-C likelihood (OR = 0.54; p = 0.046). The findings showed measurable laboratory differences between White and Black KD and MIS-C patients. Kawasaki Disease MIS-C Routine Laboratory Tests Pediatric Inflammatory Disease Introduction Pediatric inflammatory disorders have long posed diagnostic and therapeutic challenges, but the emergence of Multisystem Inflammatory Syndrome in Children (MIS-C) during the COVID-19 pandemic brought attention to this clinical domain. MIS-C, first recognized in 2020, presents with a constellation of symptoms including persistent fever, multisystem involvement, and marked inflammation of the heart, lungs, kidneys, brain, skin, eyes and gastrointestinal tract, often following recent infection with SARS-CoV-2. [ 1 , 2 ] Kawasaki Disease (KD), one of the leading causes of pediatric vasculitis in developed nations affecting up to 20 per 100,000 children under five years of age in North America. [ 3 , 4 ] MIS-C and KD can resemble each other, making a definitive diagnosis between the two challenging. Both conditions may present with fever, rash, conjunctival injection, high inflammatory markers and systemic and/or cardiac involvement. [ 5 ] This overlap highlights the need to investigate their shared pathophysiology, divergent clinical outcomes, and differences in racial distribution. [ 6 ] KD has been recognized since the 1960s as an acute, self-limiting illness, with hallmark features such as conjunctival injection, mucocutaneous changes, rash, and cervical lymphadenopathy. [ 5 ] The incidence of KD is higher in Black children than in non-Hispanic White children, with the highest rates observed among Asian populations. [ 7 – 9 ] Additionally, research has indicated that MIS-C also varies by race and is frequent among non-Hispanic Black, Hispanic, and non-Hispanic Asian or Pacific Islander persons, compared with non-Hispanic White persons. [ 10 , 11 ] Research also shows that treatment response for KD can vary by race and ethnicity. [ 12 , 13 ] This underscores the significance of early diagnosis to reduce the risk of coronary artery complications. [ 14 ] Literature has suggested KD to be the result of environmental, innate immune system disruption in genetically predisposed children or exposure to certain infectious triggers. Potential microbial contributors include superantigens like staphylococcal and streptococcal species, as well as viruses like Epstein-Barr virus, cytomegalovirus, and various human coronaviruses. Before the COVID-19 pandemic, coronaviruses such as HCoV-NL63 were investigated for their possible link to KD. A study by Esper et al. found coronavirus RNA in 72.7% of KD cases compared to 4.5% of controls, suggesting a potential association. However, this correlation has not been consistently replicated in subsequent research, leaving the exact microbial trigger of KD uncertain. [ 15 – 19 ] With the emergence of COVID-19, attention shifted to MIS-C, a condition with overlapping clinical features but distinct pathophysiology. Laboratory findings distinguish between the two conditions. MIS-C is often associated with markedly elevated inflammatory markers such as CRP, ferritin, and D-dimer, along with significant cardiac injury reflected in raised troponin and BNP levels. Hematologic abnormalities like lymphopenia and thrombocytopenia are also more common in MIS-C. [ 20 ] In contrast, KD typically exhibits elevated inflammatory markers as well, but thrombocytosis often appears in the subacute phase. A definitive diagnosis of MIS-C requires confirmed or suspected SARS-CoV-2 exposure, while KD is diagnosed through clinical criteria alone. [ 21 – 23 ] As MIS-C incidence declines, possibly due to increased immunity and vaccination of SARS-CoV-2, recognizing its unique features along with racial characteristics remains crucial for timely and appropriate treatment, particularly given its potential for sequalae and severe complications. Understanding the racial distribution and effects will allow us to address the crucial differences and systemic biases; thus, ensuring equitable outcomes. Whether these KD and MIS-C are distinct, or part of a post-infectious inflammatory continuum remains under investigation, but the clinical divergence underscores the need for differentiation. Methods A retrospective study was conducted at Children’s of Alabama after obtaining ethical approval. Patients with KD admitted between January 2000 and January 2020 and those with MIS-C between January 2021 and December 2022 were identified using the hospital’s administrative database. These records were screened to remove duplicates and exclude patients who did not meet our inclusion and exclusion criteria. Only patients with a parent-reported race of Black or White were included. KD patients were included based on the American Heart Association (AHA) diagnostic criteria and MIS-C patients were included based on the updated 2023 CDC definition. [ 10 , 24 ] Age specific range of clinical values [ 25 ] were assessed during acute phase (hospitalization) for all patients to define abnormal measurements for Hematocrit (HCT-%), C-Reactive Protein (CRP–mg/dL), Aspartate Aminotransferase (AST-U/L), Alanine Transaminase (ALT–U/L), Creatinine (Cr-mg/dL), Sodium (Na-mmol/L), Platelet count (PLT-mcL), and Erythrocyte Sedimentation Rate (ESR-mm/hr). Based on laboratory values, “Number of lab tests below the age-specific normal range” and “Number of lab tests above the age-specific normal range” were calculated by summing up the number of lab tests done at hospital admission that were either low or high for an individual. Descriptive statistics (frequency and percentage, mean ± SD for normally distributed variables and median and IQR for others) of demographics, clinical, and laboratory variables were used to summarize the data in the 2 racial groups. A multivariable logistic regression model was applied to distinguish the odds of MIS-C from KD within Black and White populations. Patients with missing laboratory values were excluded from the analysis for that variable. SAS version 9.4 (SAS institute, Cary, NC) was used for the analysis, and all statistical tests of a 2-sided P value of < .05 were considered significant. Results We analyzed a final clinical cohort of 591 patients, comprising 243 (41.1%) White KD, 43 (7.27%) White MIS-C, 249 (42.13%) Black KD and 56 (9.5%) Black MIS-C. The median age was higher for MIS-C than KD patients for both the racial groups (10 vs. 3.36 years for whites and 10 vs 2.6 years for Black children). Male predominance was seen (female: male = 1:2) (Table 1 ). CRP levels were higher in children with MIS-C than KD, with median CRP of 16.56 vs 6.51 mg/dL for White MIS-C children vs. White KD children, while ESR was elevated for KD patients from both racial groups, with a median ESR of 72 vs 51 mg/dL for Black KD vs Black MIS-C. Similarly, creatinine was found to be elevated in MIS-C patients for both the racial groups; median creatinine level of 0.34 vs 0.81 mg/dL for Black KD vs Black MIS-C. Median AST was 40 vs 29.5 U/L for White KD vs White MIS-C but this was not the case for Black children; median AST was 38 vs 43.5 U/L for Black KD vs Black MIS-C. Alternatively lower platelet counts were seen in MIS-C patients as compared to KD patients in both the races. Median PLT was 395.5 vs 202 mcL for White KD vs White MIS-C (Table 1 ). Table 2 shows the proportion of patients with abnormal laboratory values for various acute laboratory parameters in KD and MIS-C for both White and Black children along with the age-specific normal ranges for each of the variables. All the MIS-C patients (100%) had abnormal CRP similar to KD patients (98%). Higher number of MIS-C patients (28%) were seen to have abnormal sodium as compared to KD (15%). 50% of White KD participants had abnormal platelet counts. 94% of Black children with KD aged 7 to 12 years had abnormal ESR levels. Table 3 shows whether certain abnormalities (e.g., low vs. high hematocrit, sodium, platelets) are more frequent in KD or MIS-C. KD and MIS-C primarily show low hematocrit values, 55% vs 75% children aged 0.5-5 years of age had low hematocrit values. MIS-C cases show more frequently high ALT levels, especially in children 1–16 years; White MIS-C 23%, Black MIS-C 15%. Table 3 illustrates the logistic regression model differentiating MIS-C from KD. Sex is not significantly associated with differentiating MIS-C in both White and Black children (p > 0.2528). On the other hand, age is significant in differentiating MIS-C from KD (p < 0.0001 in both models), indicating that an increase in age increases the likelihood of MIS-C. For every increase in year, the odds of differentiating MIS-C from KD in Whites increases by 1.57 times. The odds of differentiating MIS-C from KD increased by 2.46 folds (in Black) and 2.93 folds (in Whites) with the number of lab tests below normal range. Number of lab tests above normal range showed significant results in differentiating MIS-C from KD in White population (p = 0.0466). Discussion This study highlights a two-way distinction in the laboratory values among the diseases and the races, comparing four groups: White KD, White MIS-C, Black KD, and Black MIS-C. It focuses on the potential lab values that could help differentiate between two conditions which can have overlapping features. Furthermore, we explored if these values differed by race. Our study found that CRP levels varied by diagnosis and race: White and Black MIS-C children had high CRP. Black children with KD mimicked median levels of CRP similar to those of MIS-C in both racial groups. While White children with KD had the lowest CRP, suggesting CRP may be less reliable for Black children in differentiating these two conditions. Almost half of children who presented with KD had abnormal platelet levels, while only 7–9% of those with MIS-C presented with platelet abnormalities with no apparent differences between racial groups. The key findings from this study are consistent with existing literature. Significantly high ESR levels are seen in KD patients as compared to MIS-C patients for both the racial groups; median ESR levels for Black KD vs Black MIS-C is 72 vs 51 mm/hr. Lee et al., in their study reported high ESR and CRP levels in KD patients as the most frequently reported finding, consistent with the findings from our study. [ 26 ] Feldstein et al showed higher CRP and lower platelet counts in MIS-C patients as compared to those patients who had COVID-19. [ 1 ] This finding stands true in the current study, not only when comparing MIS-C and KD affected children but also between the two racial groups, opening a vast opportunity to highlight laboratory values in diagnostics. We also found elevated CRP levels in MIS-C patients as compared to KD patients in both White and Black children (Table 1 ). While previous literature has highlighted the significant laboratory findings for both KD and MIS-C, this study is unique for comparison of findings stratified by race and with the inclusion of one of the largest Black KD cohorts to date, this has allowed a robust comparison between groups. All cases were drawn from the same health system within a single U.S. state, which improves consistency in data collection and clinical practices. While this localized sampling limits generalizability, it controls for institutional and geographic variability. Unequal group sizes are another limitation; however, we used statistical methods appropriate for this imbalance, and findings remain robust across cohorts. Overall, clinically, our study highlights the importance of integrating racial and laboratory data to improve diagnostic accuracy and guide personalized treatment strategies for KD and MIS-C. Public health implications include the need to expand awareness of racial differences in disease presentation and promote inclusive research practices. Future investigations should involve multi-center cohorts with diverse racial and ethnic backgrounds and incorporate genetic and social determinants of health to fully elucidate factors underlying disease expression. These steps will enhance diagnostic tools and therapeutic approaches, ultimately improving health equity in pediatric inflammatory conditions. Conclusion In Conclusion, the study emphasizes the importance of laboratory measures and age thresholds in diagnosing and differentiating MIS-C from KD while sharing the overlapping features. While both KD and MIS-C children vary significantly by race in terms of age of onset, organ involvement, and inflammatory burden, by identifying these trends, physicians may diagnose patients more quickly and accurately, promoting fair treatment for a range of pediatric groups. Declarations Data Availability Statement The deidentified data from the Children’s of Alabama that support the findings of this study are available from the corresponding author upon reasonable request, following the institutional data sharing agreement. Acknowledgments We thank the participating patients and their parents for providing their information, as well as the research staff who helped during the data extraction process at Children's of Alabama. We thank the Program in Epidemiology of Inflammation, Infection and Immunity (PEIII) Research team for valuable insights and discussion during the manuscript preparation. Funding No financial assistance was received in support of the study Author Contribution NK – Data cleaning, Analysis, Interpretation of data, Draft article, Revision LAP – Acquisition of data, Interpretation of data, Revision SC – Data cleaning, Analysis of data, HWW – Data cleaning, Analysis of data, Interpretation of data OAM – Data Cleaning, Acquisition of data, SBB – Design of study, Interpretation of data, Revision YRL – Acquisition of data, Revision MAP - Design of study, Interpretation of data, Revision SGP – Conception and Design of study, Acquisition of data, Interpretation of data, Supervision, Revision SS - Conception and Design of study, Acquisition of data, Interpretation of data, Supervision, Draft Article, All authors approved the final version of the manuscript. Competing Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Consent Statement This study obtained IRB approval to waive the requirement to obtain informed consent and use deidentified electronic medical records that are collected in the Children’s hospital. References Feldstein LR, Tenforde MW, Friedman KG et al (2021) Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA 325(11):1074. 10.1001/jama.2021.2091 Patel JM (2022) Multisystem Inflammatory Syndrome in Children (MIS-C). Curr Allergy Asthma Rep May 22(5):53–60. 10.1007/s11882-022-01031-4 Selmek K, Harding M (2024) Kawasaki Disease. Pediatr Rev 45(7):425–427. 10.1542/pir.2023-006051 Kawasaki T (2006) Kawasaki disease. 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Curr Opin Infect Dis. ;21(3) Rowley AH, Baker SC, Orenstein JM, Shulman ST (2008) Searching for the cause of Kawasaki disease — cytoplasmic inclusion bodies provide new insight. Nat Rev Microbiol 6(5):394–401. 10.1038/nrmicro1853 Bohn MK, Yousef P, Steele S, Sepiashvili L, Adeli K (2022) MultiInflammatory Syndrome in Children: A View into Immune Pathogenesis from a Laboratory Perspective. J Appl Lab Med Jan 5(1):311–321. 10.1093/jalm/jfab114 Lupu A, Gavrilovici C, Mihai CM et al (2025) Multisystem inflammatory syndrome in children and Kawasaki disease. Front Immunol 16doi. 10.3389/fimmu.2025.1554787 Sharma C, Ganigara M, Galeotti C et al (2021) Multisystem inflammatory syndrome in children and Kawasaki disease: a critical comparison. Nat Rev Rheumatol 17(12):731–748. 10.1038/s41584-021-00709-9 Melgar M, Lee EH, Miller AD et al (2022) Council of State and Territorial Epidemiologists/CDC Surveillance Case Definition for Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection - United States. MMWR Recomm Rep Dec 16(4):1–14. 10.15585/mmwr.rr7104a1 (NNDSS) CfDCaPNNDSS (2023) https://ndc.services.cdc.gov/case-definitions/multisystem-inflammatory-syndrome-in-children-mis-c-2023/ Pediatric Refrence Ranges . Fourth ed. Amer. Assoc. for Clinical Chemistry; (2003) Lee W, Cheah CS, Suhaini SA et al (2022) Clinical Manifestations and Laboratory Findings of Kawasaki Disease: Beyond the Classic Diagnostic Features. Medicina 58(6):734. 10.3390/medicina58060734 Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 13 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviews received at journal 07 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers invited by journal 30 Jan, 2026 Editor assigned by journal 27 Jan, 2026 Submission checks completed at journal 27 Jan, 2026 First submitted to journal 24 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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22:53:04\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8689314/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8689314/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":101753724,\"identity\":\"5c755227-3874-4b72-9d45-fe3906e59d24\",\"added_by\":\"auto\",\"created_at\":\"2026-02-03 10:40:37\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":415684,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8689314/v1/2bfd4e1d-cd13-486e-919d-96c0bd62c045.pdf\"},{\"id\":101650287,\"identity\":\"fd610e0c-91a8-41ae-af25-88d3465d67d8\",\"added_by\":\"auto\",\"created_at\":\"2026-02-02 09:13:29\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":26682,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Tables.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8689314/v1/a7ed39ce353b7a59b526d899.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Comparative Analysis of Routine Blood Laboratory Tests in Multisystem Inflammatory Syndrome in Children (MIS-C) and Kawasaki Disease Among White and Black Children\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePediatric inflammatory disorders have long posed diagnostic and therapeutic challenges, but the emergence of Multisystem Inflammatory Syndrome in Children (MIS-C) during the COVID-19 pandemic brought attention to this clinical domain. MIS-C, first recognized in 2020, presents with a constellation of symptoms including persistent fever, multisystem involvement, and marked inflammation of the heart, lungs, kidneys, brain, skin, eyes and gastrointestinal tract, often following recent infection with SARS-CoV-2.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/sup\\u003e Kawasaki Disease (KD), one of the leading causes of pediatric vasculitis in developed nations affecting up to 20 per 100,000 children under five years of age in North America.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]\\u003c/sup\\u003e MIS-C and KD can resemble each other, making a definitive diagnosis between the two challenging. Both conditions may present with fever, rash, conjunctival injection, high inflammatory markers and systemic and/or cardiac involvement.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]\\u003c/sup\\u003e This overlap highlights the need to investigate their shared pathophysiology, divergent clinical outcomes, and differences in racial distribution.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]\\u003c/sup\\u003e KD has been recognized since the 1960s as an acute, self-limiting illness, with hallmark features such as conjunctival injection, mucocutaneous changes, rash, and cervical lymphadenopathy.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]\\u003c/sup\\u003e The incidence of KD is higher in Black children than in non-Hispanic White children, with the highest rates observed among Asian populations.\\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR8\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]\\u003c/sup\\u003e Additionally, research has indicated that MIS-C also varies by race and is frequent among non-Hispanic Black, Hispanic, and non-Hispanic Asian or Pacific Islander persons, compared with non-Hispanic White persons.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]\\u003c/sup\\u003e Research also shows that treatment response for KD can vary by race and ethnicity.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/sup\\u003e This underscores the significance of early diagnosis to reduce the risk of coronary artery complications.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eLiterature has suggested KD to be the result of environmental, innate immune system disruption in genetically predisposed children or exposure to certain infectious triggers. Potential microbial contributors include superantigens like staphylococcal and streptococcal species, as well as viruses like Epstein-Barr virus, cytomegalovirus, and various human coronaviruses. Before the COVID-19 pandemic, coronaviruses such as HCoV-NL63 were investigated for their possible link to KD. A study by Esper et al. found coronavirus RNA in 72.7% of KD cases compared to 4.5% of controls, suggesting a potential association. However, this correlation has not been consistently replicated in subsequent research, leaving the exact microbial trigger of KD uncertain. \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR16 CR17 CR18\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eWith the emergence of COVID-19, attention shifted to MIS-C, a condition with overlapping clinical features but distinct pathophysiology. Laboratory findings distinguish between the two conditions. MIS-C is often associated with markedly elevated inflammatory markers such as CRP, ferritin, and D-dimer, along with significant cardiac injury reflected in raised troponin and BNP levels. Hematologic abnormalities like lymphopenia and thrombocytopenia are also more common in MIS-C.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]\\u003c/sup\\u003e In contrast, KD typically exhibits elevated inflammatory markers as well, but thrombocytosis often appears in the subacute phase. A definitive diagnosis of MIS-C requires confirmed or suspected SARS-CoV-2 exposure, while KD is diagnosed through clinical criteria alone.\\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR22\\\" citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eAs MIS-C incidence declines, possibly due to increased immunity and vaccination of SARS-CoV-2, recognizing its unique features along with racial characteristics remains crucial for timely and appropriate treatment, particularly given its potential for sequalae and severe complications. Understanding the racial distribution and effects will allow us to address the crucial differences and systemic biases; thus, ensuring equitable outcomes. Whether these KD and MIS-C are distinct, or part of a post-infectious inflammatory continuum remains under investigation, but the clinical divergence underscores the need for differentiation.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eA retrospective study was conducted at Children\\u0026rsquo;s of Alabama after obtaining ethical approval. Patients with KD admitted between January 2000 and January 2020 and those with MIS-C between January 2021 and December 2022 were identified using the hospital\\u0026rsquo;s administrative database. These records were screened to remove duplicates and exclude patients who did not meet our inclusion and exclusion criteria. Only patients with a parent-reported race of Black or White were included. KD patients were included based on the American Heart Association (AHA) diagnostic criteria and MIS-C patients were included based on the updated 2023 CDC definition.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]\\u003c/sup\\u003e Age specific range of clinical values\\u003csup\\u003e[\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]\\u003c/sup\\u003e were assessed during acute phase (hospitalization) for all patients to define abnormal measurements for Hematocrit (HCT-%), C-Reactive Protein (CRP\\u0026ndash;mg/dL), Aspartate Aminotransferase (AST-U/L), Alanine Transaminase (ALT\\u0026ndash;U/L), Creatinine (Cr-mg/dL), Sodium (Na-mmol/L), Platelet count (PLT-mcL), and Erythrocyte Sedimentation Rate (ESR-mm/hr). Based on laboratory values, \\u0026ldquo;Number of lab tests below the age-specific normal range\\u0026rdquo; and \\u0026ldquo;Number of lab tests above the age-specific normal range\\u0026rdquo; were calculated by summing up the number of lab tests done at hospital admission that were either low or high for an individual. Descriptive statistics (frequency and percentage, mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD for normally distributed variables and median and IQR for others) of demographics, clinical, and laboratory variables were used to summarize the data in the 2 racial groups. A multivariable logistic regression model was applied to distinguish the odds of MIS-C from KD within Black and White populations. Patients with missing laboratory values were excluded from the analysis for that variable. SAS version 9.4 (SAS institute, Cary, NC) was used for the analysis, and all statistical tests of a 2-sided P value of \\u0026lt;\\u0026thinsp;.05 were considered significant.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eWe analyzed a final clinical cohort of 591 patients, comprising 243 (41.1%) White KD, 43 (7.27%) White MIS-C, 249 (42.13%) Black KD and 56 (9.5%) Black MIS-C. The median age was higher for MIS-C than KD patients for both the racial groups (10 vs. 3.36 years for whites and 10 vs 2.6 years for Black children). Male predominance was seen (female: male\\u0026thinsp;=\\u0026thinsp;1:2) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). CRP levels were higher in children with MIS-C than KD, with median CRP of 16.56 vs 6.51 mg/dL for White MIS-C children vs. White KD children, while ESR was elevated for KD patients from both racial groups, with a median ESR of 72 vs 51 mg/dL for Black KD vs Black MIS-C. Similarly, creatinine was found to be elevated in MIS-C patients for both the racial groups; median creatinine level of 0.34 vs 0.81 mg/dL for Black KD vs Black MIS-C. Median AST was 40 vs 29.5 U/L for White KD vs White MIS-C but this was not the case for Black children; median AST was 38 vs 43.5 U/L for Black KD vs Black MIS-C. Alternatively lower platelet counts were seen in MIS-C patients as compared to KD patients in both the races. Median PLT was 395.5 vs 202 mcL for White KD vs White MIS-C (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e shows the proportion of patients with abnormal laboratory values for various acute laboratory parameters in KD and MIS-C for both White and Black children along with the age-specific normal ranges for each of the variables. All the MIS-C patients (100%) had abnormal CRP similar to KD patients (98%). Higher number of MIS-C patients (28%) were seen to have abnormal sodium as compared to KD (15%). 50% of White KD participants had abnormal platelet counts. 94% of Black children with KD aged 7 to 12 years had abnormal ESR levels.\\u003c/p\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e shows whether certain abnormalities (e.g., low vs. high hematocrit, sodium, platelets) are more frequent in KD or MIS-C. KD and MIS-C primarily show low hematocrit values, 55% vs 75% children aged 0.5-5 years of age had low hematocrit values. MIS-C cases show more frequently high ALT levels, especially in children 1\\u0026ndash;16 years; White MIS-C 23%, Black MIS-C 15%. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e illustrates the logistic regression model differentiating MIS-C from KD. Sex is not significantly associated with differentiating MIS-C in both White and Black children (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.2528). On the other hand, age is significant in differentiating MIS-C from KD (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001 in both models), indicating that an increase in age increases the likelihood of MIS-C. For every increase in year, the odds of differentiating MIS-C from KD in Whites increases by 1.57 times. The odds of differentiating MIS-C from KD increased by 2.46 folds (in Black) and 2.93 folds (in Whites) with the number of lab tests below normal range. Number of lab tests above normal range showed significant results in differentiating MIS-C from KD in White population (p\\u0026thinsp;=\\u0026thinsp;0.0466).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study highlights a two-way distinction in the laboratory values among the diseases and the races, comparing four groups: White KD, White MIS-C, Black KD, and Black MIS-C. It focuses on the potential lab values that could help differentiate between two conditions which can have overlapping features. Furthermore, we explored if these values differed by race. Our study found that CRP levels varied by diagnosis and race: White and Black MIS-C children had high CRP. Black children with KD mimicked median levels of CRP similar to those of MIS-C in both racial groups. While White children with KD had the lowest CRP, suggesting CRP may be less reliable for Black children in differentiating these two conditions. Almost half of children who presented with KD had abnormal platelet levels, while only 7\\u0026ndash;9% of those with MIS-C presented with platelet abnormalities with no apparent differences between racial groups.\\u003c/p\\u003e \\u003cp\\u003eThe key findings from this study are consistent with existing literature. Significantly high ESR levels are seen in KD patients as compared to MIS-C patients for both the racial groups; median ESR levels for Black KD vs Black MIS-C is 72 vs 51 mm/hr. Lee et al., in their study reported high ESR and CRP levels in KD patients as the most frequently reported finding, consistent with the findings from our study.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]\\u003c/sup\\u003e Feldstein et al showed higher CRP and lower platelet counts in MIS-C patients as compared to those patients who had COVID-19.\\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]\\u003c/sup\\u003e This finding stands true in the current study, not only when comparing MIS-C and KD affected children but also between the two racial groups, opening a vast opportunity to highlight laboratory values in diagnostics. We also found elevated CRP levels in MIS-C patients as compared to KD patients in both White and Black children (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWhile previous literature has highlighted the significant laboratory findings for both KD and MIS-C, this study is unique for comparison of findings stratified by race and with the inclusion of one of the largest Black KD cohorts to date, this has allowed a robust comparison between groups. All cases were drawn from the same health system within a single U.S. state, which improves consistency in data collection and clinical practices. While this localized sampling limits generalizability, it controls for institutional and geographic variability. Unequal group sizes are another limitation; however, we used statistical methods appropriate for this imbalance, and findings remain robust across cohorts.\\u003c/p\\u003e \\u003cp\\u003eOverall, clinically, our study highlights the importance of integrating racial and laboratory data to improve diagnostic accuracy and guide personalized treatment strategies for KD and MIS-C. Public health implications include the need to expand awareness of racial differences in disease presentation and promote inclusive research practices. Future investigations should involve multi-center cohorts with diverse racial and ethnic backgrounds and incorporate genetic and social determinants of health to fully elucidate factors underlying disease expression. These steps will enhance diagnostic tools and therapeutic approaches, ultimately improving health equity in pediatric inflammatory conditions.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn Conclusion, the study emphasizes the importance of laboratory measures and age thresholds in diagnosing and differentiating MIS-C from KD while sharing the overlapping features. While both KD and MIS-C children vary significantly by race in terms of age of onset, organ involvement, and inflammatory burden, by identifying these trends, physicians may diagnose patients more quickly and accurately, promoting fair treatment for a range of pediatric groups.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eData Availability Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe deidentified data from the Children\\u0026rsquo;s of Alabama that support the findings of this study are available from the corresponding author upon reasonable request, following the institutional data sharing agreement.\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe thank the participating patients and their parents for providing their information, as well as the research staff who helped during the data extraction process at Children\\u0026apos;s of Alabama. We thank the Program in Epidemiology of Inflammation, Infection and Immunity (PEIII) Research team for valuable insights and discussion during the manuscript preparation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo financial assistance was received in support of the study\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contribution\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eNK\\u003c/strong\\u003e \\u0026ndash; Data cleaning, Analysis, Interpretation of data, Draft article, Revision\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLAP\\u003c/strong\\u003e \\u0026ndash; Acquisition of data, Interpretation of data, Revision\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSC\\u003c/strong\\u003e \\u0026ndash; Data cleaning, Analysis of data,\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eHWW\\u0026nbsp;\\u003c/strong\\u003e\\u0026ndash; Data cleaning, Analysis of data, Interpretation of data\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOAM\\u0026nbsp;\\u003c/strong\\u003e\\u0026ndash; Data Cleaning, Acquisition of data,\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSBB\\u003c/strong\\u003e \\u0026ndash; Design of study, Interpretation of data, Revision\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eYRL\\u003c/strong\\u003e \\u0026ndash; Acquisition of data, Revision\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMAP\\u003c/strong\\u003e - Design of study, Interpretation of data, Revision\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSGP\\u003c/strong\\u003e \\u0026ndash; Conception and Design of study, Acquisition of data, Interpretation of data, Supervision, Revision\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSS\\u003c/strong\\u003e - Conception and Design of study, Acquisition of data, Interpretation of data, Supervision, Draft Article,\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors approved the final version of the manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003eCompeting Interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003eConsent Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study obtained IRB approval to waive the requirement to obtain informed consent and use deidentified electronic medical records that are collected in the Children\\u0026rsquo;s hospital.\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eFeldstein LR, Tenforde MW, Friedman KG et al (2021) Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. 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Assoc. for Clinical Chemistry; (2003)\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLee W, Cheah CS, Suhaini SA et al (2022) Clinical Manifestations and Laboratory Findings of Kawasaki Disease: Beyond the Classic Diagnostic Features. Medicina 58(6):734. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3390/medicina58060734\\u003c/span\\u003e\\u003cspan address=\\\"10.3390/medicina58060734\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\" \\u003cp\\u003eTables are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"pediatric-cardiology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pedc\",\"sideBox\":\"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)\",\"snPcode\":\"246\",\"submissionUrl\":\"https://submission.nature.com/new-submission/246/3\",\"title\":\"Pediatric Cardiology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Kawasaki Disease, MIS-C, Routine Laboratory Tests, Pediatric Inflammatory Disease\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8689314/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8689314/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eTo assess racial differences in disease presentation and blood laboratory parameters in improving diagnostic accuracy and management strategies for Kawasaki Disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C), a retrospective study was conducted at Children\\u0026rsquo;s of Alabama. Patients with KD, admitted between January 2000 and January 2020 and those with MIS-C, between January 2021 and December 2022 were identified using the Children\\u0026rsquo;s of Alabama hospital\\u0026rsquo;s administrative database yielding 591 records. KD patients were defined using the American Heart Association (AHA) diagnostic criteria and MIS-C patients were defined based on CDC definition. Only patients with a parent-reported race of Black or White were included. All patients with the eight key blood laboratory parameters, Hematocrit, C-Reactive Protein (CRP), Aspartate Aminotransferase (AST), Alanine Transaminase (ALT), Creatinine, Sodium, Platelet count, and Erythrocyte Sedimentation Rate (ESR) at the acute phase of the disease were included in the study. Age specific range of clinical values were assessed to define abnormal measurements. Race-specific analysis was conducted using descriptive statistics (mean, median and standard deviation). A logistic regression model using sum of abnormal lab parameters was applied to distinguish MIS-C from KD within Black and White populations. MIS-C patients were older than KD cases across both racial groups (median age 10 years vs. 3.36 years). MIS-C showed significantly elevated inflammatory markers (CRP, AST, ALT) compared to KD, suggesting a heightened systemic inflammatory response. Kidney dysfunction (elevated creatinine) was more common in Black MIS-C patients, indicating possible racial disparities in disease severity. The odds of developing MIS-C increased by 2.9 times with the total number of lab tests below normal range, whereas an increase in the number of lab tests above normal range decreased MIS-C likelihood (OR\\u0026thinsp;=\\u0026thinsp;0.54; p\\u0026thinsp;=\\u0026thinsp;0.046). The findings showed measurable laboratory differences between White and Black KD and MIS-C patients.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Comparative Analysis of Routine Blood Laboratory Tests in Multisystem Inflammatory Syndrome in Children (MIS-C) and Kawasaki Disease Among White and Black Children\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-02 09:13:21\",\"doi\":\"10.21203/rs.3.rs-8689314/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-02-13T19:50:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-12T03:11:19+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-07T19:59:11+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-04T22:40:35+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-04T12:40:41+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"308179731236091542721223295309053073360\",\"date\":\"2026-02-03T10:54:15+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"324222748088679084181120050593719614283\",\"date\":\"2026-02-02T06:38:09+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"224638479338892676547693174717543079770\",\"date\":\"2026-02-01T14:49:49+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"14612825253842794145380715793744077517\",\"date\":\"2026-01-30T15:56:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"317251526631234004040963810143059659215\",\"date\":\"2026-01-30T14:29:40+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-01-30T14:16:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-01-27T07:09:55+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-01-27T07:04:50+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Pediatric Cardiology\",\"date\":\"2026-01-24T22:36:05+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"pediatric-cardiology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pedc\",\"sideBox\":\"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)\",\"snPcode\":\"246\",\"submissionUrl\":\"https://submission.nature.com/new-submission/246/3\",\"title\":\"Pediatric Cardiology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"e4b7b431-5862-46c1-ba14-70557dcc1ea3\",\"owner\":[],\"postedDate\":\"February 2nd, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-24T06:24:44+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-02 09:13:21\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8689314\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8689314\",\"identity\":\"rs-8689314\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}