COVID-19 in Children: Initial

Characterization of the
Pediatric Disease
Andrea T. Cruz, MD, MPH,a Steven L. Zeichner, MD, PhDb

The impact of the coronavirus disease children with an increased risk for
of 2019 (COVID-19), which is caused by more significant illness. These data on
the novel coronavirus, severe acute disease severity are consistent with
respiratory syndrome coronavirus 2,1 data on non-COVID-19 coronaviruses.
has been widespread, with .500 000 The authors of one viral surveillance
cases diagnosed in .170 countries study in a PICU in China reported that
since the virus was identified in coronavirus was detected in more
January 2020.2 The preliminary data children with acute respiratory distress
have been focused on severe syndrome than human
respiratory manifestations, which are metapneumovirus.5 The authors of a
Department of Pediatrics, Baylor College of Medicine,
seen predominantly in adults, with another study conducted on Houston, Texas; and bDepartments of Pediatrics and
Microbiology, Immunology, and Cancer Biology, University of
scant initial data on the burden of hospitalized Norwegian children Virginia, Charlottesville, Virginia
COVID-19 in children.3 We, therefore, detected coronaviruses in 10% of
Opinions expressed in these commentaries are
read with interest the findings of Dong hospitalized children with respiratory
those of the authors and not necessarily those of the
et al,4 who reported in this issue of tract infections.6 Younger age, American Academy of Pediatrics or its Committees.
Pediatrics a series of .2000 children underlying pulmonary pathology, and
DOI: https://doi.org/10.1542/peds.2020-0834
with suspected or confirmed COVID-19. immunocompromising conditions have
been associated with more severe Accepted for publication Mar 13, 2020
The authors found that 4% of
virologically confirmed cases had outcomes with non-COVID-19 Address correspondence to Andrea T. Cruz, MD, MPH,
coronavirus infections in children.7 Department of Pediatrics, Baylor College of Medicine,
asymptomatic infection, and this rate
6621 Fannin St, Suite A2210, Houston, TX 77030.
almost certainly understates the true E-mail: [email protected]
Second, the attributable risk for severe
rate of asymptomatic infection because
disease from COVID-19 in children is PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
many children who are asymptomatic 1098-4275).
challenging to discern. Previous studies
are unlikely to be tested. Among
have revealed that children from whom Copyright © 2020 by the American Academy of
children who were symptomatic, 5% Pediatrics
coronaviruses are detected from the
had dyspnea or hypoxemia (a
respiratory tract can have viral co- FINANCIAL DISCLOSURE: Drs Cruz and Zeichner are
substantially lower percentage than
infections in up to two-thirds of cases.6 associate editors for Pediatrics.
what has been reported for adults3), In the study by Dong et al,4 testing for FUNDING: No external funding.
and 0.6% progressed to acute other viruses was not standardized, POTENTIAL CONFLICT OF INTEREST: The University of
respiratory distress syndrome or and two-thirds of cases were clinically Virginia has filed patent applications related to new
multiorgan system dysfunction (a rate diagnosed, not virologically confirmed. technologies for the rapid production of vaccines,
that is also lower than that seen in In addition, children without virological and Dr Zeichner is an inventor on those patent
adults). Preschool-aged children and applications; and Dr Cruz has indicated she has no
confirmation were more likely to have potential conflicts of interest to disclose.
infants were more likely than older severe disease than children from
children to have severe clinical COMPANION PAPER: A companion to this article can
whom COVID-19 was detected, be found online at www.pediatrics.org/cgi/doi/10.
manifestations. potentially because their symptoms 1542/peds.2020-0702.
were caused by other pathogens.
There are several salient points from
this article. First, although children are Third, children may play a major role in To cite: Cruz AT and Zeichner SL. COVID-19 in
Children: Initial Characterization of the Pediatric
less likely than older adults to become community-based viral transmission.
Disease. Pediatrics. 2020;145(6):e20200834
severely ill, there are subpopulations of Available data suggest that children

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PEDIATRICS Volume 145, number 6, June 2020:e20200834 COMMENTARY
may have more upper respiratory and respiratory disease in pregnant Available at: https://gisanddata.maps.a
tract involvement (including women may result in poor fetal rcgis.com/apps/opsdashboard/index.
nasopharyngeal carriage) rather than outcomes. Data on the basic html#/bda7594740fd40299423467b48e
lower respiratory tract involvement.4 reproductive number of the virus (the 9ecf6. Accessed March 11, 2020
There is also evidence of fecal number of persons to whom an 3. Wang D, Hu B, Hu C, et al. Clinical
shedding in the stool for several individual who is infected transmits characteristics of 138 hospitalized
weeks after diagnosis,8 leading to the virus) have varied widely,12,13 and patients with 2019 novel coronavirus-
concern about fecal-oral transmission household studies can be used to infected pneumonia in Wuhan, China
of the virus, particularly for infants refine the data we have on viral [published online ahead of print
February 7, 2020]. JAMA. doi:10.1001/
and children who are not toilet transmission and viral shedding.
jama.2020.1585
trained, and viral replication in the Widespread availability of testing will
gastrointestinal tract.9 Prolonged allow for us to more accurately 4. Dong Y, Mo X, Hu Y, et al. Epidemiology
shedding in nasal secretions and stool describe the spectrum of illness and of COVID-19 among children in China.
has substantial implications for may result in the adjustment of the Pediatrics. 2020;145(6):e20200702
community spread in child care apparent morbidity and mortality 5. Li YT, Liang Y, Ling YS, Duan MQ, Pan L,
centers, in schools, and in the home. rate as individuals who are less ill are Chen ZG. The spectrum of viral
Additionally, non-COVID-19 diagnosed. Although the focus for pathogens in children with severe
coronaviruses are detectable in pandemics is often on the impact on acute lower respiratory tract infection:
respiratory secretions in a large the persons who use the highest a 3-year prospective study in the
pediatric intensive care unit. J Med
percentage of healthy children,6 and resources or on the economically
Virol. 2019;91(9):1633–1642
the extent to which this is also seen in productive age groups, rigorously
COVID-19 is unclear. Prolonged viral gauging the impact of COVID-19 on 6. Heimdal I, Moe N, Krokstad S, et al.
shedding in individuals who are children will be important to Human coronavirus in hospitalized
accurately model the pandemic and to children with respiratory tract
symptomatic, combined with
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shedding in persons who are ensure that appropriate resources are
study from Norway. J Infect Dis. 2019;
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tracing and other public health Many infectious diseases affect
measures to mitigate spread children differently from adults, and 7. Ogimi C, Englund JA, Bradford MC, Qin X,
understanding those differences can Boeckh M, Waghmare A. Characteristics
less effective.
and outcomes of coronavirus infection in
yield important insights into disease
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We have learned an amazing amount pathogenesis, informing management
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PEDIATRICS Volume 145, number 6, June 2020 3
 COVID-19 in Children: Initial Characterization of the Pediatric Disease
Andrea T. Cruz and Steven L. Zeichner
Pediatrics originally published online March 16, 2020; originally published online
March 16, 2020;

Updated Information & including high resolution figures, can be found at:
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 COVID-19 in Children: Initial Characterization of the Pediatric Disease
Andrea T. Cruz and Steven L. Zeichner
Pediatrics originally published online March 16, 2020; originally published online
March 16, 2020;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2020/03/16/peds.2020-0834.1

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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