This article features both a meta-analysis and systematic review on the clinical features of pediatric inpatients with SARS-CoV-2 infection. The authors searched reputable libraries for observational studies and case series to identify clinical features and details on pediatric patients who tested positive for the virus using nucleic acid amplification tests (NAAT) between January 1, 2020 and April 21, 2020.
Pubmed, Cochrane, and Embase were searched for relevant studies. Of 545 potentially relevant results, only 15 were included in this systematic review and meta-analysis. Reports were selected that included five or more pediatric patients, and resulted in two systematic reviews, 13 retrospective studies and 2 case report studies which were relevant to this study. Careful consideration was taken to avoid overlap of patients studied.
Data extraction included demographics, clinical characteristics, lab indicators, and chest imaging in those who were used in the meta-analysis. Among inpatient pediatric patients with SARS-CoV-2 infection, the ratio of male to female was 1.64.
Symptoms: Fever (46%) and Cough (42%) were identified as the most prevalent symptoms among pediatric patients. Additional clinical characteristics include: diarrhea (10%), nasal congestion (12%), vomiting (8%), and fatigue (8%). The proportion of asymptomatic patients was (42%) with severe cases representing only (3%) of total cases involved.
Laboratory indicators in pediatric cases:
• Leukopenia (21%),
• Lymphocystosis (22%),
• High aspartate aminotransferase AST (19%),
• High C-reactive protein CRP (17%),
• Lymphopenia (16%),
• High alanine aminotransferase ALT (15%),
• Leukocytosis (13%)
• Elevated D-dimer (12%), and
• High CK-MB (5%).
Chest Imaging of Pediatric patients:
• Characteristics of pneumonia were present both unilaterally and bilaterally, with the incidence of 22% respectively.
• Most common features on Chest CT were ground-glass opacities with an incidence of 39%.
• When compared to adults, the pediatric patients had mild clinical presentations, lab indicators, and chest imaging.
Pediatrics vs. Adult Symptoms
When compared with adults, pediatric patients appear to have milder symptoms and a more favorable outcome. The absence of smoking in children may be related to the mild clinical presentation in children. In addition, other lifestyle factors may affect the clinical manifestation of COVID-19 in adults. Previous studies indicate that children were less affected by MERS and SARS due to the transmission routes and short duration of the SARS epidemic. However, children are more susceptible to pneumonia than adults.
Newborns and Infant studies:
Studies also demonstrate that among infants and newborns, whose mothers were infected with SARS-CoV-2, 3 displayed symptoms before and after delivery, but none of the infants had severe complications. One study on 9 pregnant women suggests no obvious evidence of intrauterine infection caused by vertical transmission. No evidence has been presented here that shows evidence of intrauterine infection caused by vertical transmission from mother to child.
Intestinal excretion in children:
In one case report from Singapore, asymptomatic infants were shows to shed the virus in their stool. Another study by Tan et al, reports that children persistently excrete the virus through intestinal secretion. Su et al, found that five discharged children were re-admitted due to a positive stool PCR.
For the pediatric patients with mild symptoms, antibiotics and symptomatic treatments were used. When severe, patients were transferred to the Pediatric ICU, and several of those children were intubated, given corticosteroids, and immunoglobulin.
Further studies are needed to guide the clinical diagnosis and treatment of children who are infected with SARS-CoV-2, and these studies suggest a greater focus should be on those with mild symptoms. There have been multiple meta-analyses of adult inpatient cases since SARS-CoV-2 entered the scene, however, only 2 systematic reviews with simple analysis of pediatric cases have been reported.
Research show that fever (46%) and cough (42%) were the main clinical characteristics in pediatric inpatients with SARS-CoV-2, followed by diarrhea, vomiting, nasal congestion, and fatigue which account for approximately 10% of pediatric symptoms. In lab studies, leukopenia and lymphocytosis were main indicators among pediatric patients, followed by increased AST, ALT, CRP, and D-Dimer, lymphopenia, leukocytosis, and increased CK-MB. Additionally, chest imaging shows pneumonia characteristics in both unilateral and bilateral lobes, with ground-glass opacities being prominent in 39% of cases. Children tend to have milder course of illness and better outcomes when compared to adults, but may experience higher rates of pneumonia. Newborns and infants born to COVID-19 positive mothers did not show severe complications after birth, and one study indicates no evidence of vertical transmission. Infants and children have been shown to excrete the virus from their intestinal tract, so careful consideration should be given with regards to handling waste. Further studies are needed to examine the developments in SARS-CoV-2 infection among infants and children.