Pediatric Respirology and Critical Care Medicine

: 2020  |  Volume : 4  |  Issue : 3  |  Page : 34--36

Clinical spectrum of pediatric coronavirus disease 2019 infection

Eun Lee1, Soo-Jong Hong2,  
1 Department of Pediatrics, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
2 Department of Pediatrics, Childhood Asthma Atopy Center, Humidifier Disinfectant Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

Correspondence Address:
Soo-Jong Hong
Department of Pediatrics, Childhood Asthma Atopy Center, Humidifier Disinfectant Health Center, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul 05505
Republic of Korea


Since December 2019, coronavirus disease 2019 (COVID-19) cases have been reported. The clinical features of COVID-19 in children are different from those in adults including morbidity and mortality. Even in infants and children, the clinical features are different according to ages in some cases. The children are commonly coinfected to diverse respiratory viruses, and therefore physicians, who take care of infants and children infected with COVID-19, have to consider diverse clinical aspects in their patients infected with COVID-19. In this review, we have summarized the clinical features of COVID-19 in children.

How to cite this article:
Lee E, Hong SJ. Clinical spectrum of pediatric coronavirus disease 2019 infection.Pediatr Respirol Crit Care Med 2020;4:34-36

How to cite this URL:
Lee E, Hong SJ. Clinical spectrum of pediatric coronavirus disease 2019 infection. Pediatr Respirol Crit Care Med [serial online] 2020 [cited 2022 Jan 25 ];4:34-36
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Approximately 2% of coronavirus disease 2019 (COVID-19) infection has been occurred in children and adolescents.[1] The clinical spectrum of COVID-19 in children is milder than that in adults.[2] Furthermore, children have better outcomes than adults. The clinical manifestation of COVID-19 is similar to that of other viral respiratory infections; therefore, differential diagnosis is challenging. In a systematic review and meta-analysis, the most common symptoms in children were cough (mean prevalence: 49%, 95% confidence interval [95% CI]: 42%–56%), followed by fever (mean prevalence: 47%, 95% CI: 41%–53%),[3] although the prevalence of common symptoms varies according to the study population [Table 1]. In addition, there was no sex difference in the COVID-19 infection in children.[3] Although children with COVID-19 have a mild clinical course, some children require hospitalization for the management of COVID-19-associated symptoms. In a previous study, of the 157 children requiring hospitalization because of COVID-19 pneumonia, 38.2% (n = 60), 56.1% (n = 88), and 3.8% (n = 6) children exhibited mild, moderate, and severe pneumonia, respectively.[4] In the Italian Pediatric Research networks, among the 130 children with COVID-19, nine (6.9%) children required intensive care and one (0.8%) children with cerebral palsy required intubation; however, none of the children died.[5] In a multinational and multicenter cohort study in Europe involving 582 children and adolescents (mean age: 5.0 years, interquartile range [IQR] 0.5–12.0 years) infected with COVID-19, one (0.2%) child required extracorporeal membrane oxygenation.[6] Further, 8% (n = 48) of children required intensive unit care and 4% (n = 25) of children required mechanical ventilation for a median of 7 days.[6] In addition, four children died (case fatality rate: 0.69%, 95% CI: 0.20–1.82);[6] the severity of COVID-19 in this study slightly higher than the study performed in Italy.[6] Based on the finding of several studies on COVID-19 infection in children,[3],[4],[5],[6],[7],[8] children with COVID-19 present with mild clinical symptoms; however, few children, especially those with comorbidities such as neurologic or respiratory diseases, experience severe clinical symptoms requiring intensive care with respiratory support.{Table 1}

Children of all ages are susceptible to COVID-19 infection. However, the clinical features of COVID-19 can differ according to age.[9] In a systematic review of the clinical characteristics of COVID-19 in neonates and infants aged <1 year, the most common symptom was fever (17/160, 10.6%), followed by cough (10/160, 6.3%).[9] COVID-19 in this pediatric population tends to have a more severe clinical course than that in older pediatric populations. Furthermore, compared with older children, neonates, and infants aged <1 year have an increased requirement of intensive care (11/160, 6.8%) and a higher risk of mortality (1/160, 0.6%).[9] Nevertheless, most neonates and infants aged <1 year with COVID-19 infection had favorable outcomes.[9] In neonates, transmission from family members is the most important risk factor of COVID-19 infection.[3] On the other hand, in a systematic review and meta-analysis, only 6.3% of neonates born to mothers with confirmed COVID-19 were positive for COVID-19.[3] Even in children taking immunosuppressive medications, including immunomodulators and biologics, because of diverse chronic diseases such as kidney diseases and inflammatory bowel diseases, the clinical course of COVID-19 was mild.[10]

The household transmission rate of COVID-19 is different according to the age of the first documented case within a cluster.[11] The household transmission is high if the index patient is 10–19 years of age.[11] Many children with COVID-19 infection are asymptomatic before a diagnosis of COVID-19.[2],[5] The viral shedding duration is associated with the presence and degree of respiratory symptoms of COVID-19 (mean: 11 days, IQR: 9–13 days in asymptomatic children vs. mean: 17 days, IQR: 12–23 days in symptomatic children).[2] Elevated levels of C-reactive protein (>3.0 mg/L) and procalcitonin (>0.05 ng/mL) were associated with the presence of symptoms in children with COVID-19 infection.[12] Children aged <6 years, especially those who aged <6 months, are at a higher risk of a severe COVID-19 than children aged ≥6 years.[5],[12]

Diverse extrapulmonary symptoms can manifest in children with COVID-19 infection. COVID-19-related diseases are less frequent and aggressive in children than in adults.[13] Gastrointestinal symptoms including vomiting and diarrhea and headache have been reported in 21.6%–23.6%[4],[12] and 3.4%[4] children with COVID-19 infection, respectively, compared to adults.

Although mild respiratory symptoms have been reported in most children and adolescents with COVID-19 infection, multisystem inflammatory syndrome in children (MIS-C) has been reported as a severe manifestation associated with host innate immunity in some children with COVID-19 infection.[14],[15] MIS-C is defined according to the following criteria; age <21 years, serious illness requiring hospitalization, fever (>38.0°C) or subjective fever for at least 24 h, laboratory evidence of inflammation, multisystem organ involvement, including at least two systems, confirmed COVID-19 infection, or an epidemiologic link to a person with COVID-19 infection.[14],[16] In a previous study, the most commonly involved system was the gastrointestinal system (vomiting, abdominal pain, and diarrhea; 45%–92%), followed by the cardiovascular system (myocardial dysfunction: 50%–80%), the hematologic system (deep vein thrombosis or pulmonary embolism, 76%), the mucocutaneous system (74%), and the respiratory system (respiratory insufficiency, 70%).[15] Furthermore, 80% (148/186) of patients with MIS-C received intensive care, 20% (37/186) required mechanical ventilation, and 2% (2/186) died.[15] Furthermore, 40% (74/186) of patients with MIS-C exhibited features of Kawasaki disease.[15] COVID-19-associated Kawasaki-like disease is different from the typical Kawasaki disease, in which the former is accompanied by a high prevalence of gastrointestinal symptoms and Kawasaki disease shock syndrome, which is defined by the presence of circulatory dysfunction and macrophage activation syndrome.[17],[18] In previous studies, coronary artery dilatations were present in 8%–24% in COVID-19-associated Kawasaki disease or Kawasaki-like disease cases.[15],[18] In one study from France, all of the children with COVID-19-associated Kawasaki-like disease were discharged after a mean hospitalization duration of 8 days (range: 5–17 days).[18]

In infants aged <1 year, the prevalence of fever, cough, and runny nose was significantly lower for COVID-19-associated pneumonia than for pneumonia associated with other virus infection such as influenza.[19] In addition, one study found that the mortality rate in infants with COVID-19-associated pneumonia was lower than that, in those with influenza and other coronavirus-associated pneumonia, although there was no statistical significance.[19] In addition, individuals with COVID-19 can be coinfected with other respiratory viruses such as Mycoplasma pneumoniae and bacteria;[20] the prevalence of coinfection was 5% (29/582) in a European cohort[6] and 40% (8/20) in a Chinese cohort.[20] Therefore, screening for COVID-19 in children with respiratory symptoms is required,[21] even if other pathogenic respiratory viruses or bacteria have been detected.

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