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Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and AdolescentsA Systematic Review

Educational Objective
To understand symptoms displayed in pediatric patients infected with COVID-19.
1 Credit CME
Key Points

Question  What are the clinical features of pediatric patients with coronavirus disease 2019 (COVID-19)?

Findings  In this systematic review of 18 studies with 1065 participants, most pediatric patients with SARS-CoV-2 infection presented with fever, dry cough, and fatigue or were asymptomatic; 1 infant presented with pneumonia, complicated by shock and kidney failure, and was successfully treated with intensive care. Most pediatric patients were hospitalized, and symptomatic children received mainly supportive care; no deaths were reported in the age range of 0 to 9 years.

Meaning  Most children with COVID-19 presented with mild symptoms, if any, generally required supportive care only, and typically had a good prognosis and recovered within 1 to 2 weeks.


Importance  The current rapid worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection justifies the global effort to identify effective preventive strategies and optimal medical management. While data are available for adult patients with coronavirus disease 2019 (COVID-19), limited reports have analyzed pediatric patients infected with SARS-CoV-2.

Objective  To evaluate currently reported pediatric cases of SARS-CoV-2 infection.

Evidence Review  An extensive search strategy was designed to retrieve all articles published from December 1, 2019, to March 3, 2020, by combining the terms coronavirus and coronavirus infection in several electronic databases (PubMed, Cochrane Library, and CINAHL), and following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Retrospective cross-sectional and case-control studies, case series and case reports, bulletins, and national reports about the pediatric SARS-CoV-2 infection were included. The risk of bias for eligible observational studies was assessed according to the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline.

Findings  A total of 815 articles were identified. Eighteen studies with 1065 participants (444 patients were younger than 10 years, and 553 were aged 10 to 19 years) with confirmed SARS-CoV-2 infection were included in the final analysis. All articles reflected research performed in China, except for 1 clinical case in Singapore. Children at any age were mostly reported to have mild respiratory symptoms, namely fever, dry cough, and fatigue, or were asymptomatic. Bronchial thickening and ground-glass opacities were the main radiologic features, and these findings were also reported in asymptomatic patients. Among the included articles, there was only 1 case of severe COVID-19 infection, which occurred in a 13-month-old infant. No deaths were reported in children aged 0 to 9 years. Available data about therapies were limited.

Conclusions and Relevance  To our knowledge, this is the first systematic review that assesses and summarizes clinical features and management of children with SARS-CoV-2 infection. The rapid spread of COVID-19 across the globe and the lack of European and US data on pediatric patients require further epidemiologic and clinical studies to identify possible preventive and therapeutic strategies.

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Article Information

Corresponding Author: Amelia Licari, MD, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Piazzale C. Golgi 19, 27100 Pavia, Italy (amelia.licari@unipv.it).

Accepted for Publication: April 6, 2020.

Published Online: April 22, 2020. doi:10.1001/jamapediatrics.2020.1467

Author Contributions: Dr Licari had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Castagnoli and Votto contributed equally as co–first authors.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Castagnoli, Licari, Brambilla.

Drafting of the manuscript: Castagnoli, Votto, Licari, Brambilla, Bruno.

Critical revision of the manuscript for important intellectual content: Licari, Brambilla, Perlini, Rovida, Baldanti, Marseglia.

Statistical analysis: Castagnoli, Votto, Licari.

Administrative, technical, or material support: Perlini.

Supervision: Licari, Brambilla, Perlini, Baldanti, Marseglia.

Conflict of Interest Disclosures: None reported.

Guan  WJ , Ni  ZY , Hu  Y ,  et al; China Medical Treatment Expert Group for Covid-19.  Clinical Characteristics of Coronavirus Disease 2019 in China.   N Engl J Med. Published online February 28, 2020. doi:10.1056/NEJMoa2002032PubMedGoogle Scholar
Lu  R , Zhao  X , Li  J ,  et al.  Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding.   Lancet. 2020;395(10224):565-574. doi:10.1016/S0140-6736(20)30251-8PubMedGoogle ScholarCrossref
Zhu  N , Zhang  D , Wang  W ,  et al; China Novel Coronavirus Investigating and Research Team.  A novel coronavirus from patients with pneumonia in China, 2019.   N Engl J Med. 2020;382(8):727-733. doi:10.1056/NEJMoa2001017PubMedGoogle ScholarCrossref
World Health Organization (WHO). WHO Director-General's opening remarks at the media briefing on COVID-19: 11 March 2020. Published March 11, 2020. Accessed March 11, 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
Xu  Y , Li  X , Zhu  B ,  et al.  Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding.   Nat Med. Published online March 13, 2020. doi:10.1038/s41591-020-0817-4Google Scholar
Hoffmann  M , Kleine-Weber  H , Schroeder  S ,  et al.  SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor.   Cell. Published online March 4, 2020. doi:10.1016/j.cell.2020.02.052PubMedGoogle Scholar
Moher  D , Liberati  A , Tetzlaff  J , Altman  DG ; PRISMA Group.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.   PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097PubMedGoogle Scholar
Stroup  DF , Berlin  JA , Morton  SC ,  et al.  Meta-analysis of observational studies in epidemiology: a proposal for reporting: Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.   JAMA. 2000;283(15):2008-2012. doi:10.1001/jama.283.15.2008PubMedGoogle ScholarCrossref
von Elm  E , Altman  DG , Egger  M , Pocock  SJ , Gøtzsche  PC , Vandenbroucke  JP ; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.   Int J Surg. 2014;12(12):1495-1499. doi:10.1016/j.ijsu.2014.07.013PubMedGoogle ScholarCrossref
Tong  ZD , Tang  A , Li  KF ,  et al.  Potential presymptomatic transmission of SARS-CoV-2, Zhejiang province, China, 2020.   Emerg Infect Dis. 2020;26(5). doi:10.3201/eid2605.200198PubMedGoogle Scholar
Cai  JH , Wang  XS , Ge  YL ,  et al.  [First case of 2019 novel coronavirus infection in children in Shanghai].   Zhonghua Er Ke Za Zhi. 2020;58(2):86-87. doi:10.3760/cma.j.issn.0578-1310.2020.02.002PubMedGoogle Scholar
Shen  KL , Yang  YH .  Diagnosis and treatment of 2019 novel coronavirus infection in children: a pressing issue.   World J Pediatr. Published online February 5, 2020. doi:10.1007/s12519-020-00344-6PubMedGoogle Scholar
Song  F , Shi  N , Shan  F ,  et al.  Emerging 2019 novel coronavirus (2019-nCoV) pneumonia.   Radiology. 2020;295(1):210-217. doi:10.1148/radiol.2020200274PubMedGoogle ScholarCrossref
Chang  D , Lin  M , Wei  L ,  et al.  Epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside Wuhan, China.   JAMA. Published online February 7, 2020. doi:10.1001/jama.2020.1623PubMedGoogle Scholar
Schwartz  DA , Graham  AL .  Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: lessons from SARS, MERS, and other human coronavirus infections.   Viruses. 2020;12(2):e194. doi:10.3390/v12020194PubMedGoogle Scholar
Zhang  YH , Lin  DJ , Xiao  MF ,  et al.  [2019-novel coronavirus infection in a three-month-old baby].   Zhonghua Er Ke Za Zhi. 2020;58(0):e006. doi:10.3760/cma.j.issn.0578-1310.2020.0006PubMedGoogle Scholar
Chen  F , Liu  ZS , Zhang  FR ,  et al.  [First case of severe childhood novel coronavirus pneumonia in China].   Zhonghua Er Ke Za Zhi. 2020;58(3):179-182. doi:10.3760/cma.j.issn.0578-1310.2020.03.003PubMedGoogle Scholar
Wei  M , Yuan  J , Liu  Y , Fu  T , Yu  X , Zhang  ZJ .  Novel coronavirus infection in hospitalized infants under 1 year of age in China.   JAMA. Published online February 7, 2020. doi:10.1001/jama.2020.2131PubMedGoogle Scholar
Chan  JF , Yuan  S , Kok  KH ,  et al.  A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.   Lancet. 2020;395(10223):514-523. doi:10.1016/S0140-6736(20)30154-9PubMedGoogle ScholarCrossref
Zhang  MQ , Wang  XH , Chen  YL ,  et al.  [Clinical features of 2019 novel coronavirus pneumonia in the early stage from a fever clinic in Beijing].   Zhonghua Jie He Hu Xi Za Zhi. 2020;43(0):E013. doi:10.3760/cma.j.issn.1001-0939.2020.0013PubMedGoogle Scholar
Feng  K , Yun  YX , Wang  XF ,  et al.  [Analysis of CT features of 15 children with 2019 novel coronavirus infection].   Zhonghua Er Ke Za Zhi. 2020;58(0):E007. doi:10.3760/cma.j.issn.0578-1310.2020.0007PubMedGoogle Scholar
Zeng  LK , Tao  XW , Yuan  WH , Wang  J , Liu  X , Liu  ZS .  [First case of neonate infected with novel coronavirus pneumonia in China].   Zhonghua Er Ke Za Zhi. 2020;58(0):E009. doi:10.3760/cma.j.issn.0578-1310.2020.0009PubMedGoogle Scholar
Pediatric Branch of Hubei Medical Association; Pediatric Branch of Wuhan Medical Association; Pediatric Medical Quality Control Center of Hubei.  [Recommendation for the diagnosis and treatment of novel coronavirus infection in children in Hubei (trial version 1)].   Zhongguo Dang Dai Er Ke Za Zhi. 2020;22(2):96-99.PubMedGoogle Scholar
Wu  Z , McGoogan  JM .  Characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648PubMedGoogle Scholar
Tian  S , Hu  N , Lou  J ,  et al  Characteristics of COVID-19 infection in Beijing.   J Infect. 2020;80(4):401-406. doi:10.1016/j.jinf.2020.02.018Google ScholarCrossref
Cai  J , Xu  J , Lin  D ,  et al.  A case series of children with 2019 novel coronavirus infection: clinical and epidemiological features.   Clin Infect Dis. Published online February 28, 2020. doi:10.1093/cid/ciaa198PubMedGoogle Scholar
Kam  KQ , Yung  CF , Cui  L ,  et al.  A well infant with coronavirus disease 2019 (COVID-19) with high viral load.  [published online February 27, 2020].  Clin Infect Dis. 2020;ciaa201. doi:10.1093/cid/ciaa201PubMedGoogle Scholar
World Health Organization. Coronavirus disease 2019 (COVID-19): situation report 45. Published March 5, 2020. Accessed March 5, 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200305-sitrep-45-covid-19.pdf?sfvrsn=ed2ba78b_4
Han  Q , Lin  Q , Jin  S , You  L.   Coronavirus 2019-nCoV: a brief perspective from the front line.   J Infect. 2020;80(4):373-377. doi:10.1016/j.jinf.2020.02.010Google ScholarCrossref
Sun  P , Lu  X , Xu  C , Sun  W , Pan  B .  Understanding of COVID-19 based on current evidence.   J Med Virol. Published online February 25, 2020. doi:10.1002/jmv.25722PubMedGoogle Scholar
Chen  ZM , Fu  JF , Shu  Q ,  et al.  Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel coronavirus.  [published online February 25, 2020].  World J Pediatr. 2020. doi:10.1007/s12519-020-00345-5PubMedGoogle Scholar
Onder  G , Rezza  G , Brusaferro  S .  Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy.   JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683PubMedGoogle Scholar
Chen  T , Wu  D , Chen  H ,  et al.  Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study.   BMJ. 2020;368:m1091. doi:10.1136/bmj.m1091PubMedGoogle ScholarCrossref
Zhou  F , Yu  T , Du  R ,  et al.  Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.   Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3PubMedGoogle ScholarCrossref
Rasmussen  SA , Thompson  LA .  Coronavirus disease 2019 and children: what pediatric health care clinicians need to know.   JAMA Pediatr. Published online April 3, 2020. doi:10.1001/jamapediatrics.2020.1224PubMedGoogle Scholar
Chen  H , Guo  J , Wang  C ,  et al.  Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.   Lancet. 2020;395(10226):809-815. doi:10.1016/S0140-6736(20)30360-3PubMedGoogle ScholarCrossref
Lu  Q , Shi  Y .  Coronavirus disease (COVID-19) and neonate: what neonatologist need to know.   J Med Virol. Published online February 25, 2020. doi:10.1002/jmv.25740PubMedGoogle Scholar
UNICEF. Coronavirus disease (COVID-19): What parents should know. Accessed March 3, 2020. https://www.unicef.org/stories/novel-coronavirus-outbreak-what-parents-should-know
Working Group for the Prevention and Control of Neonatal 2019-nCoV Infection in the Perinatal Period of the Editorial Committee of Chinese Journal of Contemporary Pediatrics.  [Perinatal and neonatal management plan for prevention and control of 2019 novel coronavirus infection (1st Edition)].   Zhongguo Dang Dai Er Ke Za Zhi. 2020;22(2):87-90.Google Scholar
Wang  D , Ju  XL , Xie  F ,  et al.  [Clinical analysis of 31 cases of 2019 novel coronavirus infection in children from six provinces (autonomous region) of northern China].   Zhonghua Er Ke Za Zhi. 2020;58(4):e011. doi:10.3760/cma.j.cn112140-20200225-00138PubMedGoogle Scholar
Bi  Q , Wu  Y , Mei  S ,  et al.  Epidemiology and transmission of COVID-19 in Shenzhen China: analysis of 391 cases and 1,286 of their close contacts.  Preprint. Posted online March 27, 2020. medRxiv. doi:10.1101/2020.03.03.20028423
Arabi  YM , Mandourah  Y , Al-Hameed  F ,  et al; Saudi Critical Care Trial Group.  Corticosteroid therapy for critically ill patients with Middle East respiratory syndrome.   Am J Respir Crit Care Med. 2018;197(6):757-767. doi:10.1164/rccm.201706-1172OCPubMedGoogle ScholarCrossref
Behzadi  MA , Leyva-Grado  VH .  Overview of current therapeutics and novel candidates against influenza, respiratory syncytial virus, and Middle East respiratory syndrome coronavirus infections.   Front Microbiol. 2019;10:1327. doi:10.3389/fmicb.2019.01327PubMedGoogle ScholarCrossref
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