Clinical characteristics and diagnostic challenges of pediatric COVID-19: A systematic review and meta-analysis
Identifieur interne : 001141 ( Pmc/Corpus ); précédent : 001140; suivant : 001142Clinical characteristics and diagnostic challenges of pediatric COVID-19: A systematic review and meta-analysis
Auteurs : Tu-Hsuan Chang ; Jhong-Lin Wu ; Luan-Yin ChangSource :
- Journal of the Formosan Medical Association [ 0929-6646 ] ; 2020.
Abstract
Current studies on pediatric coronavirus disease 2019 (COVID-19) are rare. The clinical characteristics and spectrum are still unknown. Facing this unknown and emerging pathogen, we aimed to collect current evidence about COVID-19 in children.
We performed a systematic review in PubMed and Embase to find relevant case series. Because some reports were published in Chinese journals, the journals and publications of the Chinese Medical Association related to COVID-19 were completely reviewed. A random effects model was used to pool clinical data in the meta-analysis.
Nine case series were included. In the pooled data, most of patients (75%) had a household contact history. The disease severity was mainly mild to moderate (98%). Only 2 children (2%) received intensive care. Fever occurred in 59% of the patients, while cough in 46%. Gastrointestinal symptoms (12%) were uncommon. There are 26% children are asymptomatic. The most common radiographic finding was ground glass opacities (48%). Currently, there is no evidence of vertical transmission to neonates born to mothers with COVID-19. Compared with the most relevant virus, SARS-CoV, SARS-CoV-2 causes less severe disease.
COVID-19 has distinct features in children. The disease severity is mild. Current diagnosis is based mainly on typical ground glass opacities on chest CT, epidemiological suspicion and contact tracing.
Url:
DOI: 10.1016/j.jfma.2020.04.007
PubMed: NONE
PubMed Central: 7161491
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Clinical characteristics and diagnostic challenges of pediatric COVID-19: A systematic review and meta-analysis</title><author><name sortKey="Chang, Tu Hsuan" sort="Chang, Tu Hsuan" uniqKey="Chang T" first="Tu-Hsuan" last="Chang">Tu-Hsuan Chang</name><affiliation><nlm:aff id="aff1">Chi-Mei Medical Center, Tainan, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Wu, Jhong Lin" sort="Wu, Jhong Lin" uniqKey="Wu J" first="Jhong-Lin" last="Wu">Jhong-Lin Wu</name><affiliation><nlm:aff id="aff2">National Taiwan University Hospital, Taipei, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Chang, Luan Yin" sort="Chang, Luan Yin" uniqKey="Chang L" first="Luan-Yin" last="Chang">Luan-Yin Chang</name><affiliation><nlm:aff id="aff2">National Taiwan University Hospital, Taipei, Taiwan</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7161491</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161491</idno><idno type="RBID">PMC:7161491</idno><idno type="doi">10.1016/j.jfma.2020.04.007</idno><idno type="pmid">NONE</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">001141</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001141</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Clinical characteristics and diagnostic challenges of pediatric COVID-19: A systematic review and meta-analysis</title><author><name sortKey="Chang, Tu Hsuan" sort="Chang, Tu Hsuan" uniqKey="Chang T" first="Tu-Hsuan" last="Chang">Tu-Hsuan Chang</name><affiliation><nlm:aff id="aff1">Chi-Mei Medical Center, Tainan, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Wu, Jhong Lin" sort="Wu, Jhong Lin" uniqKey="Wu J" first="Jhong-Lin" last="Wu">Jhong-Lin Wu</name><affiliation><nlm:aff id="aff2">National Taiwan University Hospital, Taipei, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Chang, Luan Yin" sort="Chang, Luan Yin" uniqKey="Chang L" first="Luan-Yin" last="Chang">Luan-Yin Chang</name><affiliation><nlm:aff id="aff2">National Taiwan University Hospital, Taipei, Taiwan</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of the Formosan Medical Association</title><idno type="ISSN">0929-6646</idno><idno type="eISSN">0929-6646</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background/Purpose</title><p>Current studies on pediatric coronavirus disease 2019 (COVID-19) are rare. The clinical characteristics and spectrum are still unknown. Facing this unknown and emerging pathogen, we aimed to collect current evidence about COVID-19 in children.</p></sec><sec><title>Methods</title><p>We performed a systematic review in PubMed and Embase to find relevant case series. Because some reports were published in Chinese journals, the journals and publications of the Chinese Medical Association related to COVID-19 were completely reviewed. A random effects model was used to pool clinical data in the meta-analysis.</p></sec><sec><title>Results</title><p>Nine case series were included. In the pooled data, most of patients (75%) had a household contact history. The disease severity was mainly mild to moderate (98%). Only 2 children (2%) received intensive care. Fever occurred in 59% of the patients, while cough in 46%. Gastrointestinal symptoms (12%) were uncommon. There are 26% children are asymptomatic. The most common radiographic finding was ground glass opacities (48%). Currently, there is no evidence of vertical transmission to neonates born to mothers with COVID-19. Compared with the most relevant virus, SARS-CoV, SARS-CoV-2 causes less severe disease.</p></sec><sec><title>Conclusion</title><p>COVID-19 has distinct features in children. The disease severity is mild. Current diagnosis is based mainly on typical ground glass opacities on chest CT, epidemiological suspicion and contact tracing.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Li, Q" uniqKey="Li Q">Q. Li</name></author><author><name sortKey="Guan, X" uniqKey="Guan X">X. Guan</name></author><author><name sortKey="Wu, P" uniqKey="Wu P">P. Wu</name></author><author><name sortKey="Wang, X" uniqKey="Wang X">X. Wang</name></author><author><name sortKey="Zhou, L" uniqKey="Zhou L">L. Zhou</name></author><author><name sortKey="Tong, Y" uniqKey="Tong Y">Y. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Formos Med Assoc</journal-id><journal-id journal-id-type="iso-abbrev">J. Formos. Med. Assoc</journal-id><journal-title-group><journal-title>Journal of the Formosan Medical Association</journal-title></journal-title-group><issn pub-type="ppub">0929-6646</issn><issn pub-type="epub">0929-6646</issn><publisher><publisher-name>Formosan Medical Association. Published by Elsevier Taiwan LLC.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7161491</article-id><article-id pub-id-type="publisher-id">S0929-6646(20)30143-1</article-id><article-id pub-id-type="doi">10.1016/j.jfma.2020.04.007</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Clinical characteristics and diagnostic challenges of pediatric COVID-19: A systematic review and meta-analysis</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Chang</surname><given-names>Tu-Hsuan</given-names></name><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Wu</surname><given-names>Jhong-Lin</given-names></name><xref rid="aff2" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Chang</surname><given-names>Luan-Yin</given-names></name><email>lychang@ntu.edu.tw</email><xref rid="aff2" ref-type="aff">b</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib></contrib-group><aff id="aff1"><label>a</label>Chi-Mei Medical Center, Tainan, Taiwan</aff><aff id="aff2"><label>b</label>National Taiwan University Hospital, Taipei, Taiwan</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding author. Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, 8 Chung-Shan South Road, Taipei 10041, Taiwan. Fax: +886 2 2314 7450. <email>lychang@ntu.edu.tw</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>16</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>16</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>17</day><month>3</month><year>2020</year></date><date date-type="rev-recd"><day>7</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>9</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Formosan Medical Association. Published by Elsevier Taiwan LLC.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><sec><title>Background/Purpose</title><p>Current studies on pediatric coronavirus disease 2019 (COVID-19) are rare. The clinical characteristics and spectrum are still unknown. Facing this unknown and emerging pathogen, we aimed to collect current evidence about COVID-19 in children.</p></sec><sec><title>Methods</title><p>We performed a systematic review in PubMed and Embase to find relevant case series. Because some reports were published in Chinese journals, the journals and publications of the Chinese Medical Association related to COVID-19 were completely reviewed. A random effects model was used to pool clinical data in the meta-analysis.</p></sec><sec><title>Results</title><p>Nine case series were included. In the pooled data, most of patients (75%) had a household contact history. The disease severity was mainly mild to moderate (98%). Only 2 children (2%) received intensive care. Fever occurred in 59% of the patients, while cough in 46%. Gastrointestinal symptoms (12%) were uncommon. There are 26% children are asymptomatic. The most common radiographic finding was ground glass opacities (48%). Currently, there is no evidence of vertical transmission to neonates born to mothers with COVID-19. Compared with the most relevant virus, SARS-CoV, SARS-CoV-2 causes less severe disease.</p></sec><sec><title>Conclusion</title><p>COVID-19 has distinct features in children. The disease severity is mild. Current diagnosis is based mainly on typical ground glass opacities on chest CT, epidemiological suspicion and contact tracing.</p></sec></abstract><kwd-group id="kwrds0010"><title>Keywords</title><kwd>Children</kwd><kwd>COVID-19</kwd><kwd>SARS-CoV-2</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Introduction</title><p id="p0010">In December 2019, an outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) occurred in Wuhan, Hubei Province, China.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> COVID-19 has spread rapidly to other provinces of China and now internationally. On January 30, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern (PHEIC). As of April 7, 1,279,722 cases were confirmed, and 72,616 (5.7%) patients died in 211 countries. In the beginning of the outbreak, COVID-19 was considered a zoonotic disease with limited human-to-human transmission. Initially, pneumonia cases were linked to the Huanan Seafood Wholesale Market. Soon after, this emerging coronavirus was found to be highly infectious. The basic reproductive number ranged from 2.2 to 3.58, with a mean serial interval of 7.5 days.<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref></p><p id="p0015">Children are more susceptible than adults to some infectious diseases, which may cause fatal outcomes. For instance, young children, especially infants aged less than 6 months, have higher mortality rates due to seasonal influenza infection than individuals in other age groups.<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref> During enterovirus outbreaks, enterovirus 71 and echoviruses lead to death in different age groups of children.<xref rid="bib5" ref-type="bibr"><sup>5</sup></xref><sup>,</sup><xref rid="bib6" ref-type="bibr"><sup>6</sup></xref><italic>Streptococcus pneumoniae</italic> and <italic>Haemophilus influenzae</italic> type b were associated with high childhood mortality in the era without conjugate vaccines.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref></p><p id="p0020">The clinical spectrum of COVID-19 ranges from asymptomatic to critically ill cases. Fever and cough are the most common manifestations in symptomatic adults.<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><sup>,</sup><xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> It seems that SARS-CoV-2 is less invasive in children than in adults. However, reports about the clinical characteristics of pediatric COVID-19 are limited. Facing this unknown and emerging pathogen, we aimed to collect current evidence about COVID-19 in children.</p></sec><sec id="sec2"><title>Method</title><p id="p0025">We performed a systematic literature search in PubMed and Embase using the following terms: “coronavirus or COVID-19 or 2019-nCoV or SARS-CoV-2” and “pediatric or neonate or newborn or infant or children or adolescence” to find reports of pediatric COVID-19. Since the novel coronavirus was identified in January 2020, the time period was restricted to not include literature published prior to this time point. Available full texts and the reference lists of the relevant studies were reviewed. There was no language restriction in our search. Since some reports were published in Chinese journals, the journals and publications of the Chinese Medical Association related to COVID-19 were completely reviewed. Google Scholar was searched manually for possible missing articles. The last update of the study was on March 15, 2020.</p><p id="p0030">Two independent reviewers (THC, JLW) screened all titles and abstracts for eligibility. Studies were eligible for inclusion if they met the following criteria: 1) patients were younger than 18 years old, and 2) COVID-19 was diagnosed by PCR. Repeated calculations in other publications or clinical diagnoses of COVID-19 cases without laboratory confirmation were excluded. Correspondences or letters fulfilling the above criteria were also included.</p><sec id="sec2.1"><title>Data extraction and quality assessment</title><p id="p0035">After full-text screening for eligibility and review, two authors (THC, LYC) independently extracted data. Disagreements were resolved by consensus. The following items were extracted from each study, if available: author, journal, date of publication, study design, study country, time period, contact or travel history, clinical symptoms, laboratory results, complications, and chest computed tomography (CT) findings. The publication date, author, hospital and case report content were carefully examined to avoid repeated calculation during data pooling. The quality of studies included in meta-analysis was assessed using the Newcastle–Ottawa Scale (NOS). Articles with poor quality (score = 0–3) were excluded.</p></sec><sec id="sec2.2"><title>Data synthesis and analysis</title><p id="p0040">We presented the data with descriptive statistics and pooled the available data for overall demonstration. Disease severity was categorized into four types according to officially published guideline in China: 1) Mild type: Asymptomatic or some upper respiratory tract infection signs; 2) Moderate type: The above manifestations with pneumonia in imaging study; 3) Severe type: Disease progression with danger signs; 4) Critical type: Shock or organ failure needing intensive care.<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> The pooled data were further compared with those for laboratory-confirmed severe acute respiratory syndrome (SARS) children reported in previous studies. Categorical data were compared with the chi-square test. A p-value less than 0.05 by a two-tailed test was considered statistically significant. When at least 3 studies with available data reported the same characteristic, we used Comprehensive Meta-Analysis version 3 (Biostat, Englewood, NJ) to conduct meta-analysis. We used random effects models to calculate the pooled frequency among each clinical manifestation or outcome. The results are expressed as incidences and 95% CIs. I<sup>2</sup> was calculated to examine statistical heterogeneity across the included studies. I<sup>2</sup> > 50% and a p < 0.05 were considered substantial heterogeneity. Egger precision weighted linear regression tests and funnel plots were used to test potential publication bias. If publication bias was present, the trim and fill method would be performed and Rosenthal's Fail-safe N would be calculated to evaluate the effect.</p></sec></sec><sec id="sec3"><title>Results</title><p id="p0045"><xref rid="fig1" ref-type="fig">Fig. 1</xref>shows the flow diagram of the study selection process. A total of 190 articles were identified in the initial search. After removing duplicates, 113 were screened by titles and abstracts. Obviously irrelevant articles were excluded. The remaining 13 were retrieved for full text assessment. Seven records were identified through manual searches of Google Scholar (n = 1) and the Chinese Medical Journal Network (n = 6). After qualitative synthesis, we excluded 11 articles. Ten articles were case reports. One study investigating infant cases was excluded because the patient profile was extracted from a national database. Considering repeated calculations and missing data, we did not include this study in the pooled data. In our search, we found 9 case series related to pediatric COVID-19.<fig id="fig1"><label>Figure 1</label><caption><p>Flow diagram of the study selection process.</p></caption><alt-text id="alttext0010a">Figure 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig></p><sec id="sec3.1"><title>Epidemiological and clinical features</title><p id="p0050">In <xref rid="tbl1" ref-type="table">Table 1</xref>and <xref rid="tbl2" ref-type="table">Table 2</xref>, we summarize the epidemiological and clinical features of pediatric COVID-19. The study period ranged from January 2020 to February 2020. The reported population included all age groups, from neonates to adolescents. Most of them (75%) had a clear household contact history. No gender difference among these studies. The majority of patients were categorized as having mild to moderate disease severity (98%). More than half (59%, 95% CI 0.41–0.72; I<sup>2</sup> = 44%, p = 0.10) of the patients presented with fever. About 46% (95% CI 0.27–0.66; I<sup>2</sup> = 57%, p = 0.03) of the patients had a cough. Only a few (12%, 95% CI 0.06–0.32; I<sup>2</sup> = 45%, p = 0.09) patients had gastrointestinal manifestations. Approximately 26% (95% CI 0.13–0.52; I<sup>2</sup> = 63%, p = 0.01) of patients showed no specific symptoms initially. However, the result revealed moderate heterogeneity. Regarding laboratory results, lymphopenia (lymphocytes < 1500 × 10<sup>9</sup>/L) was found in 32% (95% CI 0.05–0.83; I<sup>2</sup> = 72%, p = 0.03) of infected children. Some children (9%, 95% CI 0.04–0.46; I<sup>2</sup> = 20%, p = 0.28) even developed severe lymphopenia (lymphocytes < 1000 × 10<sup>9</sup>/L).<table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>Characteristics and summary data of included studies.</p></caption><alt-text id="alttext0015c">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>Liu et al.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref></th><th>Feng et al.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></th><th>Cai et al.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref></th><th>Xia et al.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref></th><th>Wang et al.<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref></th><th>Jiang et al.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref></th><th>Li et al.<xref rid="bib17" ref-type="bibr"><sup>17</sup></xref></th></tr></thead><tbody><tr><td>Case number</td><td>6</td><td>15</td><td>10</td><td>20</td><td>31</td><td>6</td><td>5</td></tr><tr><td>Regions</td><td>Hubei</td><td>Shenzhen</td><td>Multiple</td><td>Wuhan</td><td>Multiple</td><td>Chongqing</td><td>Zhuhai</td></tr><tr><td>Median age, y</td><td>3 y</td><td>7 y</td><td>6.5 y</td><td>2 y</td><td>7 y</td><td>7 y</td><td>3 y</td></tr><tr><td>Age range</td><td>1 y–7 y</td><td>4 y–14 y</td><td>3 m–10 y</td><td>1 d–14 y</td><td>6 m–17 y</td><td>7 m–14 y</td><td>10 m–6 y</td></tr><tr><td>Male No. (%)</td><td>2 (33)</td><td>5 (33)</td><td>4 (40)</td><td>13 (65)</td><td>15 (48)</td><td>5 (83)</td><td>4 (80)</td></tr><tr><td>Household contact<hr></hr></td><td>0 (0)<hr></hr></td><td>12 (80)<hr></hr></td><td>7 (70)<hr></hr></td><td>13 (65)<hr></hr></td><td>28 (90)<hr></hr></td><td>6 (100)<hr></hr></td><td>4 (80)<hr></hr></td></tr><tr><td>Disease severity<hr></hr></td><td colspan="7">No. (%)<hr></hr></td></tr><tr><td> Mild</td><td>2 (33)</td><td>3 (20)</td><td>6 (60)</td><td>4 (20)</td><td>17 (55)</td><td>3 (50)</td><td>2 (40)</td></tr><tr><td> Moderate</td><td>3 (50)</td><td>12 (80)</td><td>4 (40)</td><td>15 (75)</td><td>14 (45)</td><td>3 (50)</td><td>3 (60)</td></tr><tr><td> Severe</td><td>1 (17)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td></tr><tr><td> Critical</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>1 (5)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td></tr><tr><td colspan="8">Clinical features</td></tr><tr><td> Asymptomatic</td><td>0 (0)</td><td>8 (53)</td><td>0 (0)</td><td>2 (10)</td><td>7 (23)</td><td>3 (50)</td><td>4 (80)</td></tr><tr><td> Fever</td><td>6 (100)</td><td>5 (33)</td><td>8 (80)</td><td>12 (60)</td><td>20 (65)</td><td>3 (50)</td><td>1 (20)</td></tr><tr><td> Cough</td><td>6 (100)</td><td>1 (7)</td><td>6 (60)</td><td>13 (65)</td><td>14 (45)</td><td>2 (33)</td><td>1 (20)</td></tr><tr><td> GI symptoms</td><td>4 (67)</td><td>0 (0)</td><td>0 (0)</td><td>3 (15)</td><td>3 (10)</td><td>1 (17)</td><td>0 (0)</td></tr><tr><td>Lymphocyte <1500, x10<sup>9</sup>/L</td><td>5 (83)</td><td>–</td><td>1 (10)</td><td>–</td><td>–</td><td>1 (17)</td><td>–</td></tr><tr><td>Lymphocyte <1000, x10<sup>9</sup>/L</td><td>2 (33)</td><td>–</td><td>0 (0)</td><td>–</td><td>–</td><td>0 (0)</td><td>–</td></tr><tr><td colspan="8">Chest CT findings</td></tr><tr><td> Patchy consolidations</td><td>3/5<xref rid="tbl1fna" ref-type="table-fn">a</xref> (60)</td><td>2 (13)</td><td>–</td><td>20</td><td>–</td><td>1 (17)</td><td>0 (0)</td></tr><tr><td> Ground glass opacities</td><td>1/5<xref rid="tbl1fna" ref-type="table-fn">a</xref> (20)</td><td>7 (47)</td><td>–</td><td>10 (50)</td><td>–</td><td>2 (33)</td><td>3 (60)</td></tr><tr><td> No lesion</td><td>1/5<xref rid="tbl1fna" ref-type="table-fn">a</xref> (20)</td><td>6 (40)</td><td>–</td><td>12 (60)</td><td>–</td><td>1 (17)</td><td>2 (40)</td></tr><tr><td colspan="8">Outcomes</td></tr><tr><td> Intensive care</td><td>1 (17)</td><td>0 (0)</td><td>0 (0)</td><td>1 (5)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td></tr><tr><td> Complication</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>1 (5)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td></tr></tbody></table><table-wrap-foot><fn><p>Data are shown as numbers (%).</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl1fna"><label>a</label><p id="ntpara0010f">Number with positive results/number with available data.</p></fn></table-wrap-foot></table-wrap><table-wrap position="float" id="tbl2"><label>Table 2</label><caption><p>Pooled epidemiological and clinical features of COVID-19 in pediatric case series.</p></caption><alt-text id="alttext0010">Table 2</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>Pooled value</th><th></th><th>Pooled value</th><th></th></tr></thead><tbody><tr><td>Epidemiological dataCase numbers</td><td>93 (100)</td><td>Disease severityMild to moderate</td><td>91 (98)</td><td></td></tr><tr><td>Male</td><td>48 (52)</td><td>Severe</td><td>1 (1)</td><td></td></tr><tr><td>Household contact<hr></hr></td><td>70 (75)<hr></hr></td><td>Critical<hr></hr></td><td>1 (1)<hr></hr></td><td><hr></hr></td></tr><tr><td>Clinical features</td><td>Pooled value</td><td>95% CI</td><td>I<sup>2</sup></td><td>p value</td></tr><tr><td> Asymptomatic</td><td>24 (26)</td><td>0.13 – 0.52</td><td>63 %</td><td>0.01</td></tr><tr><td> Fever</td><td>55 (59)</td><td>0.41 – 0.72</td><td>44 %</td><td>0.10</td></tr><tr><td> Cough</td><td>43 (46)</td><td>0.27 – 0.66</td><td>57 %</td><td>0.03</td></tr><tr><td> GI symptoms</td><td>11 (12)</td><td>0.06 – 0.32</td><td>45 %</td><td>0.09</td></tr><tr><td>Lymphocyte <1500, x10<sup>9</sup>/L</td><td>7/22<xref rid="tbl2fna" ref-type="table-fn">a</xref> (32)</td><td>0.05 – 0.83</td><td>72 %</td><td>0.03</td></tr><tr><td>Lymphocyte <1000, x10<sup>9</sup>/L</td><td>2/22<xref rid="tbl2fna" ref-type="table-fn">a</xref> (9)</td><td>0.04 – 0.46</td><td>20 %</td><td>0.28</td></tr><tr><td colspan="5">Outcome</td></tr><tr><td> Intensive care</td><td>2 (2)</td><td>0.02 – 0.14</td><td>0 %</td><td>0.88</td></tr><tr><td> Complication</td><td>1 (1)</td><td>0.02 – 0.12</td><td>0 %</td><td>0.98</td></tr></tbody></table><table-wrap-foot><fn><p>Data are shown as numbers (%).</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl2fna"><label>a</label><p id="ntpara0010">Number with positive results/number with available data.</p></fn></table-wrap-foot></table-wrap></p></sec><sec id="sec3.2"><title>Radiographic findings</title><p id="p0055"><xref rid="tbl3" ref-type="table">Table 3</xref>shows the pooled frequency of initial chest CT findings in 3 pediatric COVID-19 case series. Patchy consolidation and ground glass opacities were the most common radiographic features, which occurred in 31% (95% CI 0.13–0.55; I<sup>2</sup> = 51%, p = 0.09) and 48% (95% CI 0.36–0.64; I<sup>2</sup> = 5%, p = 0.52) of these patients. In 27% (95% CI 0.18–0.43; I<sup>2</sup> = 0%, p = 0.64) of the patients, there was no definite lung lesion.<table-wrap position="float" id="tbl3"><label>Table 3</label><caption><p>Pooled frequency of initial chest CT findings in pediatric COVID-19.</p></caption><alt-text id="alttext0025">Table 3</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>Pooled value</th><th>95% CI</th><th>I<sup>2</sup></th><th>p value</th></tr></thead><tbody><tr><td>Patchy consolidations</td><td>16 (31)</td><td>0.13–0.55</td><td>51%</td><td>0.09</td></tr><tr><td>Ground glass opacities</td><td>25 (48)</td><td>0.36–0.64</td><td>0%</td><td>0.52</td></tr><tr><td>No lesion</td><td>14 (27)</td><td>0.18–0.43</td><td>0%</td><td>0.64</td></tr></tbody></table><table-wrap-foot><fn><p>Data are shown as numbers (%).</p></fn></table-wrap-foot></table-wrap></p></sec><sec id="sec3.3"><title>Neonates born to mothers with COVID-19</title><p id="p0060">In <xref rid="tbl4" ref-type="table">Table 4</xref>, we provide the current data about neonates born to mothers with COVID-19. Most of the pregnant women (78–89%) had fever at some point during hospitalization and received a Cesarean section (78–100%). Approximately half (44–60%) of the babies were preterm. Hence, gestational age affected birth weight. There was no difference between the two cohorts in initial Apgar score. No neonatal death was mentioned. In addition, all neonates tested negative for SARS-CoV-2.<table-wrap position="float" id="tbl4"><label>Table 4</label><caption><p>Demographics and outcomes of neonates born to mothers with COVID-19.</p></caption><alt-text id="alttext0030">Table 4</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>Chen et al.<xref rid="bib18" ref-type="bibr"><sup>18</sup></xref></th><th>Zhu et al.<xref rid="bib19" ref-type="bibr"><sup>19</sup></xref></th></tr></thead><tbody><tr><td>Number<hr></hr></td><td>9<hr></hr></td><td>10 (1 twin)<hr></hr></td></tr><tr><td>Maternal history<hr></hr></td><td colspan="2">No. (%)<hr></hr></td></tr><tr><td> Cesarean-section</td><td>9 (100)</td><td>7 (78)</td></tr><tr><td> Fever<hr></hr></td><td>7 (78)<hr></hr></td><td>8 (89)<hr></hr></td></tr><tr><td>Neonate outcomes<hr></hr></td><td colspan="2">No. (%)<hr></hr></td></tr><tr><td> Gestational age (weeks)</td><td>37 (36–39)</td><td>34 (31–39)</td></tr><tr><td> Preterm birth</td><td>4 (44)</td><td>6 (60)</td></tr><tr><td> Low birth weight (<2500 g)</td><td>2 (22)</td><td>7 (70)</td></tr><tr><td> 1 min Apgar score</td><td>9</td><td>9</td></tr><tr><td> 5 min Apgar score</td><td>10</td><td>10</td></tr><tr><td> Positive for SARS-CoV-2</td><td>0 (0)</td><td>0 (0)</td></tr><tr><td> Neonatal death</td><td>0 (0)</td><td>NA</td></tr></tbody></table><table-wrap-foot><fn><p>Data are shown as numbers (%).</p></fn></table-wrap-foot></table-wrap></p></sec><sec id="sec3.4"><title>Comparison of the clinical features between SARS and COVID-19 in children</title><p id="p0065">In <xref rid="tbl5" ref-type="table">Table 5</xref>, we compare laboratory-confirmed SARS children in previous studies<xref rid="bib20" ref-type="bibr">20</xref>, <xref rid="bib21" ref-type="bibr">21</xref>, <xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib23" ref-type="bibr">23</xref> and COVID-19 children in our review. Household or direct contact represents the major transmission route for both coronavirus diseases. However, SARS in children is more severe than COVID-19. Children infected with SARS-CoV tended to have more fever (98% vs. 59%, p < 0.001) than those with COVID-19. Symptomatic infection is also more common with SARS than with COVID-19 (100% vs. 74%, p < 0.001). Overall, COVID-19 seems less invasive than SARS in pediatric patients. However, the proportion of patients requiring intensive care shows no statistical difference (10% vs. 2%, p = 0.06).<table-wrap position="float" id="tbl5"><label>Table 5</label><caption><p>Comparing the clinical features between SARS and COVID-19 in children.</p></caption><alt-text id="alttext0015">Table 5</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>SARS (N=80)</th><th>COVID-19 (N=93)</th><th></th></tr></thead><tbody><tr><td>Years of outbreak</td><td>2002–2003</td><td>2020</td><td></td></tr><tr><td>Household or direct contact</td><td>66–100%</td><td>75%</td><td></td></tr><tr><td>Clinical features</td><td></td><td></td><td>p value</td></tr><tr><td> Asymptomatic</td><td>0 (0)</td><td>24 (26)</td><td><0.001</td></tr><tr><td> Fever</td><td>78 (98)</td><td>55 (59)</td><td><0.001</td></tr><tr><td> Cough</td><td>48 (60)</td><td>43 (46)</td><td>0.02</td></tr><tr><td> Lymphopenia (<1500, x10<sup>9</sup>/L)</td><td>37 (46)</td><td>7/22∗ (32)</td><td>0.33</td></tr><tr><td> Intensive care</td><td>6/59<xref rid="tbl5fna" ref-type="table-fn">a</xref> (10)</td><td>2 (2)</td><td>0.06</td></tr><tr><td> Mortality rate</td><td>0 (0)</td><td>Very low</td><td>–</td></tr></tbody></table><table-wrap-foot><fn><p>Data are shown as numbers (%).</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl5fna"><label>a</label><p id="ntpara0015">Number with positive results/number with available data.</p></fn></table-wrap-foot></table-wrap></p></sec></sec><sec id="sec4"><title>Discussion</title><p id="p0070">This review summarized currently available observational studies about pediatric COVID-19, from neonates to adolescents. The number of COVID-19 cases has increased worldwide. According to the largest epidemiologic survey, the age distribution of these patients is mainly 30–79 years (87%).<xref rid="bib24" ref-type="bibr"><sup>24</sup></xref> The elderly and people with chronic diseases are most susceptible to critical forms of COVID-19. There are relatively few cases among children. Patients under 19 years old accounted for 2.2% of 44,672 confirmed cases.<xref rid="bib24" ref-type="bibr"><sup>24</sup></xref> Only one death was recorded. The crude mortality rate is extremely low (0.1%) compared with that in current published data for adults (2.3%–14.6%).<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><sup>,</sup><xref rid="bib9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="bib24" ref-type="bibr"><sup>24</sup></xref><sup>,</sup><xref rid="bib25" ref-type="bibr"><sup>25</sup></xref></p><p id="p0075">The clinical data in pediatric COVID-19 have to be reviewed with caution. Most of the authors in our review used the “Diagnosis and Treatment Protocol for 2019-nCoV. 5th ed” to categorize disease severity.<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> We unified the pooled data according to this classification. Based on this rule, the disease severity in children seems to be mild or moderate. Mild disease makes the clinical features subtle and transient. Hence, the proportion of asymptomatic patients varied among studies. Also, one retrospective study was conducted before mid-January.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> The result might be representative of the early stage of COVID-19 outbreak. Therefore, more symptomatic or severe cases were reported, the same as adults,<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><sup>,</sup><xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> which make moderate heterogeneity of the pooled data in clinical features. Despite the benign presentation of pediatric COVID-19, a 1-year-old boy, who was classified as critical in one report,<xref rid="bib26" ref-type="bibr"><sup>26</sup></xref> presented with vomiting and diarrhea for 6 days. There was no obvious cough or respiratory tract symptom initially. His condition deteriorated quickly after admission. Shock developed and soon progressed to acute respiratory distress syndrome (ARDS), so he received mechanical ventilation. Acute kidney injury with hemodialysis also occurred during admission. Prompt diagnosis is more challenging in pediatric cases with unusual presentations.</p><p id="p0080">Compared with other pandemic or epidemic viral illnesses, the small numbers of cases and low mortality rate in pediatric COVID-19 are of great interest. Compared with the most relevant virus, SARS-CoV, SARS-CoV-2 causes less severe disease. Human angiotensin-converting enzyme 2 (ACE2) is proposed to be the key factor. ACE2 is the primary entry receptor for both coronaviruses. After replacing four out of five important interface amino acid residues from SARS-CoV, the affinity of SARS-CoV-2 for ACE2 is weaker.<xref rid="bib27" ref-type="bibr"><sup>27</sup></xref> Nevertheless, SARS-CoV-2 still exhibits significant binding affinity to human ACE2. The binding strength of SARS-CoV-2 to ACE2 partially explains why it causes less severe disease than SARS-CoV but remains highly infectious. However, this result did not answer the question of why children are spared from severe COVID-19. In previous studies, SARS-CoV induced higher ACE2 shedding than human coronavirus NL63. The differential downregulation of ACE2 is related to lung injury.<xref rid="bib28" ref-type="bibr"><sup>28</sup></xref> In one study about the pathophysiology of acute respiratory distress syndrome (ARDS), increasing age led to an imbalance of the pulmonary renin-angiotensin system, which correlates with aggravated inflammation and enhanced lung injury in a rat model.<xref rid="bib29" ref-type="bibr"><sup>29</sup></xref> Nevertheless, no age-dependent differences in ACE and ACE2 were seen in a prospective observational cohort study.<xref rid="bib30" ref-type="bibr"><sup>30</sup></xref> There is one hypothesis that smoking increases ACE2 expression and thus enhances coronavirus entry into pulmonary epithelial cells.<xref rid="bib31" ref-type="bibr"><sup>31</sup></xref> Undoubtedly, smoking is more prevalent among adults than among children. Nonetheless, some controversies exist.<xref rid="bib32" ref-type="bibr"><sup>32</sup></xref> Another important fact is that children rarely have underlying diseases, such as diabetes mellitus, chronic obstructive pulmonary disease or cardiovascular diseases, as adults do. These underlying diseases may predispose patients to critical conditions during COVID-19. However, the definite pathogenesis is unknown. Therefore, the severity difference between adults and children with COVID-19 needs more investigation.</p><p id="p0085">The diagnosis of pediatric COVID-19 is a challenge. In China, clinicians should have a suspicion of COVID-19 when patients meet one epidemiological history with two clinical manifestations. According to our literature review, the main symptoms in pediatric COVID-19 are fever and cough, resembling common viral illness frequently encountered in school or kindergarten.<xref rid="bib33" ref-type="bibr"><sup>33</sup></xref> Epidemiological features are the main diagnostic clue. Children with familial clustering, contact with infected cases, travel or living in areas with persistent local transmission within 14 days prior to disease onset are at risk of being infected with SARS-CoV-2. Since COVID-19 has spread to many other countries, the epidemiological history should be modified outside mainland China. In addition, asymptomatic cases are a potential source of infection. Although only 1% of the patients had been reported as asymptomatic,<xref rid="bib24" ref-type="bibr"><sup>24</sup></xref> 26% of infected children were asymptomatic in the pooled data. Namely, children may act as silent carriers or spreaders.<xref rid="bib34" ref-type="bibr"><sup>34</sup></xref> Notably, an asymptomatic infection does not always mean a carrier. Chan et al. presented a familial cluster with one family member, a 10-year-old boy, who tested positive for SARS-CoV-2. Without symptoms, he had ground glass lung opacities identified incidentally by CT scan.<xref rid="bib35" ref-type="bibr"><sup>35</sup></xref> A similar scenario occurred in another report: chest CT performed in one asymptomatic child revealed patchy density.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> This finding raised another issue that needs to be further considered. According to our review, the radiographic findings in pediatric COVID-19 are similar to those in adults.<xref rid="bib36" ref-type="bibr"><sup>36</sup></xref> In China, chest CT has been used as a screening tool for COVID-19. The disease severity and clinical suspicion are associated with radiographic findings. However, this diagnostic policy might not be applicable in all countries.</p><p id="p0090">Household contact and epidemic area travel history are two major transmission routes for SARS. SARS-CoV-2 shows the same characteristics. Familial clustering is a strong epidemiological link with COVID-19, especially in children. Some reports have already demonstrated that asymptomatic infections in children occurred in family clusters.<xref rid="bib35" ref-type="bibr"><sup>35</sup></xref><sup>,</sup><xref rid="bib37" ref-type="bibr"><sup>37</sup></xref><sup>,</sup><xref rid="bib38" ref-type="bibr"><sup>38</sup></xref> Because of the high asymptomatic ratio, pediatric COVID-19 cases are usually detected by contact tracing. Unfortunately, presymptomatic or asymptomatic transmission of SARS-CoV-2 has been reported.<xref rid="bib38" ref-type="bibr"><sup>38</sup></xref><sup>,</sup><xref rid="bib39" ref-type="bibr"><sup>39</sup></xref> The transmission of SARS-CoV-2 via asymptomatic children is reasonable. To date, no clustering or asymptomatic transmission among children has been documented. There are some possible explanations. First, the outbreak of COVID-19 occurred during winter vacation for students. Moreover, the Chinese government imposed lockdowns and travel restrictions in Hubei Province beginning on January 24, 2020. Furthermore, the government announced that the Lunar New Year holiday would be extended to February 2, 2020 across the country. The new semester in school will also be postponed indefinitely. These events limited the community spread of SARS-CoV-2 within school-age children. However, contact tracing and case isolation alone may be unlikely to control the SARS-CoV-2 outbreak in pediatric groups when a new semester starts.</p><p id="p0095">There are some important issues not addressed in our review. First, the outbreak of COVID-19 occurred 2 months ago, so detailed case descriptions and clinical courses are limited. In addition, some patients are still hospitalized and quarantined. The long-term outcome and sequelae may need further follow-up. Second, critical or fatal pediatric COVID-19 cases are rare, indicating that the risk factors and protective factors are still unknown. Third, there are often multiple viral infections that mimic COVID-19 circulating in the same class or the same school. In areas outside China, how to recognize COVID-19 early in children and implement infection control is an urgent problem. Fourth, the treatment strategy in children may need additional debate and caution. In some pediatric cases in China, lopinavir, ritonavir and inhaled recombinant human interferon alpha have been applied. However, the efficacy and safety have not yet been reported.</p><p id="p0100">In conclusion, compared with SARS, COVID-19 has distinct features in children. There are more asymptomatic and mild cases, which make diagnosis and infection source control more challenging. Current diagnosis is based mainly on typical ground glass opacities on chest CT, epidemiological suspicion and contact tracing.</p></sec><sec sec-type="COI-statement"><title>Declaration of Competing Interest</title><p id="p0105">The authors have no conflicts of interest relevant to this article.</p></sec></body><back><ref-list id="cebib0010"><title>References</title><ref id="bib1"><label>1</label><element-citation publication-type="journal" id="sref1"><person-group person-group-type="author"><name><surname>Li</surname><given-names>Q.</given-names></name><name><surname>Guan</surname><given-names>X.</given-names></name><name><surname>Wu</surname><given-names>P.</given-names></name><name><surname>Wang</surname><given-names>X.</given-names></name><name><surname>Zhou</surname><given-names>L.</given-names></name><name><surname>Tong</surname><given-names>Y.</given-names></name></person-group><article-title>Early transmission dynamics in Wuhan, China, of novel coronavirus-infected 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MOST 108-2321-B-002-016 and MOST 109-2634-F-002-029 to LY Chang. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.</p></ack></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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