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SARS-CoV-2 Infection in Children

Our take —

This study was among the first to demonstrate that a substantial proportion of children with COVID-19 remained asymptomatic over the course of the disease, and that severe disease requiring intensive care was very rare among children <16 years old. The screening process enabled the inclusion of asymptomatic cases; however, the study population may not be a representative sample of all children with COVID-19 infections in Wuhan. The clinical course observed in this study, where the children remained under hospital care for the duration of their infections, may differ from the clinical course without this level of care.

Study design

Case Series

Study population and setting

This study included children under age 16 who had known contact with a confirmed or suspected COVID-19 case and tested positive for COVID-19 between January 28, 2020 – February 26, 2020 at Wuhan Children’s Hospital, the single designated site for COVID-19 testing and treatment for children under age 16 in Wuhan, China. As part of control efforts in Wuhan, any person with an infection, regardless of symptoms, was hospitalized to isolate them from others and prevent transmission. 171 children under age 16 (median age 6.7 years; 61% male) were enrolled and followed up through March 8, 2020.

Summary of Main Findings

16% of the confirmed child infections had no symptoms or radiologic indications of pneumonia on CT scan throughout the follow-up period, while 19% had upper respiratory tract infection without pneumonia, and 65% had pneumonia. The most common symptoms were cough (49%), pharyngeal erythema (46%), and fever (42%). The ground glass-like opacity was the most common abnormality detected on chest CT (33%). Only 3 children required intensive care support, all of whom had underlying medical conditions; one died.

Study Strengths

China’s control strategy included screening all people exposed to a confirmed or suspected case of COVID-19 and hospitalizing them to control transmission. Therefore, all children with infections were included in this study and there are no concerns about missing children who did not seek care or who did not have severe disease, and thus represented a broader range of clinical presentations among children, including asymptomatic infection. Symptoms were observed throughout the course of infection, minimizing the potential for misclassifying pre-symptomatic children as asymptomatic. Data included clinical symptoms and outcomes, comprehensive serologic parameters, and radiographic evaluation. Quality control procedures were described for the extraction of medical records, which were from the single clinical site caring for children in Wuhan.

Limitations

Though the largest study of children with COVID-19 at the time of publication, the sample size is small, and there were not enough severe events to investigate risk factors for progression; data were descriptive only. It is impossible to know what proportion of infected children in the population were missed by the screening process; those missed would be more likely to be asymptomatic. Authors did not report the prevalence and handling of missing or incomplete data.

Value added

This is one of the earliest and most comprehensive reports on the clinical course of COVID-19 infection among children.