Clinical manifestations of children with COVID-19

Elderly patients infected with SARS-CoV-2 are at high risk to have Severe Acute Respiratory Syndrome (SARS), complications and death.

Due to unknown reasons, children with COVID-19 appear to have a milder clinical course compared to adults, and reports of death are scarce. However, pediatric population may play a major role in community spread of SARS-CoV-2. In addition to viral shedding in nasal secretions, there is evidence of fecal shedding for several weeks after diagnosis, which poses a challenge for infection control.

However, despite the epidemiological importance, clinical patterns of children with COVID-19 remain unclear, so the aim of a new study was to describe the clinical, laboratorial and radiological characteristics of children with COVID-19 ―the WHO recommends testing all suspected cases, however, children infected with SARS-CoV-2 may not meet all the criteria required in the suspected case definition―.

In this way, the Medline database was searched between December 1st 2019 and March 30th 2020 with next inclusion criteria were: studied patients younger than 18 years old; presented original data from cases of COVID-19 confirmed by reverse-transcription polymerase chain reaction; and contained descriptions of clinical manifestations, laboratory tests or radiological examinations.

As data extractions authors pointed to: number of cases, gender, age, clinical manifestations, laboratory tests, radiological examinations and outcomes. When sufficient data was reported, the cases were classified into the following clinical types:

  • Asymptomatic infection: without any clinical symptoms and signs and the chest imaging is normal, while the SARS-CoV-2 nucleic acid test was positive or the serum-specific antibody was retrospectively diagnosed as infection.
  • Mild: symptoms of acute upper respiratory tract infection, including fever, fatigue, myalgia, cough, sore throat, runny nose, and sneezing. Physical examination shows congestion of the pharynx and no auscultatory abnormalities. Some cases may have no fever, or have only digestive symptoms such as nausea, vomiting, abdominal pain and diarrhea.
  • Moderate: presented as pneumonia. Frequent fever and cough, mostly dry cough, followed by productive cough, some may have wheezing, but no obvious hypoxemia such as shortness of breath, and lungs can hear sputum or dry snoring and/or wet snoring. Some cases may have no clinical signs and symptoms, but chest computed tomography (CT) shows lung lesions, which are subclinical.
  • Severe: early respiratory symptoms such as fever and cough, may be accompanied by gastrointestinal symptoms such as diarrhea. The disease usually progresses around 1 week, and dyspnea occurs, with central cyanosis. Oxygen saturation is less than 92%, with other hypoxia manifestations.
  • Critical: children can quickly progress to Acute Respiratory Distress Syndrome (ARDS) or respiratory failure, and may also have shock, encephalopathy, myocardial injury or heart failure, coagulation dysfunction, and acute kidney injury, including multiple organ dysfunction.

A total of 38 studies (1,124 cases) were included. From all the cases, 1,117 had their severity classified: 14.2% were asymptomatic, 36.3% were mild, 46.0% were moderate, 2.1% were severe and 1.2% were critical. The most prevalent symptom was fever (47.5%), followed by cough (41.5%), nasal symptoms (11.2%), diarrhea (8.1%) and nausea/vomiting (7.1%). 36.9% children were diagnosed with pneumonia and 10.9% upper airway infections were reported. Reduced lymphocyte count were reported in 12.9% of cases. Abnormalities on Computed Tomography (CT) Scan was reported in 63.0% of cases. The most prevalent abnormalities reported were ground glass opacities, patchy shadows and consolidations. Only one death was reported.

Finally, authors suggest clinical manifestations of children with COVID-19 differ widely from adults cases, since fever and respiratory symptoms should not be considered a hallmark of COVID-19 in children.

Link to the paper: https://doi.org/10.1101/2020.04.01.20049833

Editorial Disclaimer: information published during the 2020 COVID-19 pandemic may be updated frequently to reflect the dynamic nature of current understanding.

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