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Epidemiological characteristics of 2143 children with COVID-19

Excerpt

We conducted a retrospective study on the epidemiological characteristics of 2143 children (< 18 years old) with [confirmed or strongly suspected] COVID-19. Suspected cases were identified if a child at high risk had two of the following conditions:

  • fever or respiratory symptoms or digestive symptoms (e.g., vomiting, nausea and diarrhea) or fatigue
  • WBC is normal or decreased or with lymphocyte count or increased level of C-reactive protein
  • abnormal chest X-ray imaging

Editor’s note: the requirement of “two of the following” runs into immediate difficulties. The first bullet offers four generic symptoms common to most sick children. The second bullet includes an unclear message (should the lymphocyte count be high, low or either?). The chest x-ray should clearly be abnormal, but then that could possibly mean anything, including the perihilar infiltrates of bronchiolitis, the lobar consolidation characteristic of pneumonia, the hyperinflation seen in asthma. Two thirds (731/1412) of the children in this report remained “suspected” cases.

Diagnostic criteria were as follows:

  1. Asymptomatic infection: without any clinical symptoms and signs and the chest imaging is normal, while the 2019-nCoV nucleic acid test is in a positive period.
  2. 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 auscultory abnormalities. Some cases may have no fever, or have only digestive symptoms such as nausea, vomiting, abdominal pain and diarrhea.
  3. Moderate: with 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 CT shows lung lesions, which are subclinical.
  4. 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.
  5. 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. Organ dysfunction can be life threatening.

Young children, particularly infants, were vulnerable to 2019-nCoV infection. The proportion of severe and critical cases was 10.6 %, 7.3%, 4.2%, 4.1% and 3.0% for the age group of <1, 1-5, 6-10, 11-15 and ≥16 years, respectively. There were more severe and critical cases in the suspected than confirmed category. However, it remains to be determined whether these severe and critical cases in the suspected group were caused by 2019-nCoV or other pathogens (e.g., RSV).

As of 8 February 2020, of the 2143 pediatric patients included in this study, only one child died (14 y.o.), and most cases were mild, with much fewer severe and critical cases (5.9%) than adult patients (18.5%). It suggests that, compared with adult patients, clinical manifestations of children’s COVID-19 may be less severe.

SOURCE: Pediatrics (pre-publication release)

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[pdf_attachment file=”1″ name=”Cruz+Zeichner (pre-publication)”]

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Initial characterization of pediatric COVID-19

Excerpt

Dong and colleagues report a series of over 2000 children in China with suspected or confirmed COVID-19. The authors found that 13% of virologically-confirmed cases had asymptomatic infection, a rate that almost certainly understates the true rate of asymptomatic infection, since many asymptomatic children are unlikely to be tested. Among symptomatic children, 5% had dyspnea or hypoxemia (a substantially lower percentage than what has been reported for adults) and 0.6% progressed to acute respiratory distress syndrome (ARDS) or multiorgan system dysfunction, a rate that is also lower than that seen in adults. Preschool-aged children and infants were more likely to have severe clinical manifestations than older children.

While children are less likely to become severely ill than older adults, there are subpopulations of children with an increased risk for more significant illness. These are consistent with data on non-COVID-19 coronaviruses. One viral surveillance study in a pediatric intensive care unit in China reported that coronavirus was detected more often than human metapneumovirus in children with ARDS. Another study in hospitalized Norwegian children detected coronaviruses in 10% of hospitalized children with respiratory tract infections. Younger age, underlying pulmonary pathology, and immunocompromising conditions have been associated with more severe outcomes with non-COVID-19 coronavirus infections in children.

Children may play a major role in community-based viral transmission. Available data suggest that children may have more upper respiratory tract (including nasopharyngeal carriage), rather than lower respiratory tract involvement. There is also evidence of fecal shedding in the stool for several weeks after diagnosis, leading to concern about fecal-oral transmission of the virus, particularly for infants and children who are not toilet-trained, and for viral replication in the gastrointestinal tract. Prolonged shedding in nasal secretions and stool has substantial implications for community spread in daycare centers, schools, and in the home. Additionally, non-COVID-19 coronaviruses are detectable in respiratory secretions in a large percentage of healthy children, and the extent to which this is also seen in COVID-19 is unclear.

Prolonged viral shedding in symptomatic individuals, combined with shedding in asymptomatic persons, would render contact tracing and other public health measures to mitigate spread less effective.

SOURCE: Pediatrics (pre-publication release)

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[pdf_attachment file=”2″ name=”Dong et al (pre-publication)”]