SARS-CoV-2 Infection in Children
To the Editor:
As of March 10, 2020, the 2019 novel coronavirus (SARS-CoV-2) has been responsible for more than 110,000 infections and 4000 deaths worldwide, but data regarding the epidemiologic characteristics and clinical features of infected children are limited.1-3 A recent review of 72,314 cases by the Chinese Center for Disease Control and Prevention showed that less than 1% of the cases were in children younger than 10 years of age.2 In order to determine the spectrum of disease in children, we evaluated children infected with SARS-CoV-2 and treated at the Wuhan Children’s Hospital, the only center assigned by the central government for treating infected children under 16 years of age in Wuhan. Both symptomatic and asymptomatic children with known contact with persons having confirmed or suspected SARS-CoV-2 infection were evaluated. Nasopharyngeal or throat swabs were obtained for detection of SARS-CoV-2 RNA by established methods.4 The clinical outcomes were monitored up to March 8, 2020.
Of the 1391 children assessed and tested from January 28 through February 26, 2020, a total of 171 (12.3%) were confirmed to have SARS-CoV-2 infection. Demographic data and clinical features are summarized in Table 1. (Details of the laboratory and radiologic findings are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) The median age of the infected children was 6.7 years. Fever was present in 41.5% of the children at any time during the illness. Other common signs and symptoms included cough and pharyngeal erythema. A total of 27 patients (15.8%) did not have any symptoms of infection or radiologic features of pneumonia. A total of 12 patients had radiologic features of pneumonia but did not have any symptoms of infection. During the course of hospitalization, 3 patients required intensive care support and invasive mechanical ventilation; all had coexisting conditions (hydronephrosis, leukemia [for which the patient was receiving maintenance chemotherapy], and intussusception). Lymphopenia (lymphocyte count, <1.2×109 per liter) was present in 6 patients (3.5%). The most common radiologic finding was bilateral ground-glass opacity (32.7%). As of March 8, 2020, there was one death. A 10-month-old child with intussusception had multiorgan failure and died 4 weeks after admission. A total of 21 patients were in stable condition in the general wards, and 149 have been discharged from the hospital.
Table 1
Characteristic | Value |
---|---|
Age | |
Median (range) | 6.7 yr (1 day–15 yr) |
Distribution — no. (%) | |
<1 yr | 31 (18.1) |
1–5 yr | 40 (23.4) |
6–10 yr | 58 (33.9) |
11–15 yr | 42 (24.6) |
Sex — no. (%) | |
Male | 104 (60.8) |
Female | 67 (39.2) |
Diagnosis — no. (%) | |
Asymptomatic infection | 27 (15.8) |
Upper respiratory tract infection | 33 (19.3) |
Pneumonia | 111 (64.9) |
Exposure or contact information — no. (%) | |
Family cluster | 154 (90.1) |
Confirmed family members | 131 (76.6) |
Suspected family members | 23 (13.5) |
Unidentified source of infection | 15 (8.8) |
Contact with other suspected case | 2 (1.2) |
Signs and symptoms | |
Cough — no. (%) | 83 (48.5) |
Pharyngeal erythema — no. (%) | 79 (46.2) |
Fever — no. (%) | 71 (41.5) |
Median duration of fever (range) — days | 3 (1–16) |
Highest temperature during hospitalization — no. (%) | |
<37.5°C | 100 (58.5) |
37.5–38.0°C | 16 (9.4) |
38.1–39.0°C | 39 (22.8) |
>39.0°C | 16 (9.4) |
Diarrhea — no. (%) | 15 (8.8) |
Fatigue — no. (%) | 13 (7.6) |
Rhinorrhea — no. (%) | 13 (7.6) |
Vomiting — no. (%) | 11 (6.4) |
Nasal congestion — no. (%) | 9 (5.3) |
Tachypnea on admission — no. (%)† | 49 (28.7) |
Tachycardia on admission — no. (%)‡ | 72 (42.1) |
Oxygen saturation <92% during period of hospitalization — no. (%) | 4 (2.3) |
Abnormalities on computed tomography of the chest — no. (%) | |
Ground-glass opacity | 56 (32.7) |
Local patchy shadowing | 32 (18.7) |
Bilateral patchy shadowing | 21 (12.3) |
Interstitial abnormalities | 2 (1.2) |
*
Percentages may not total 100 because of rounding.
†
The normal ranges of respiratory rate (in breaths per minute) were as follows: 40 to 60 for newborns, 30 to 40 for children younger than 1 year of age, 25 to 30 for those 1 to 3 years of age, 20 to 25 for those 4 to 7 years of age, 18 to 20 for those 8 to 14 years of age, and 12 to 20 for those older than 14 years of age. Tachypnea refers to a respiratory rate higher than the upper limit of the normal range according to age.
‡
The normal ranges of pulse rate (in beats per minute) were as follows: 120 to 140 for newborns, 110 to 130 for children younger than 1 year of age, 100 to 120 for those 1 to 3 years of age, 80 to 100 for those 4 to 7 years of age, 70 to 90 for those 8 to 14 years of age, and 60 to 70 for those older than 14 years of age. Tachycardia refers to a pulse rate higher than the upper limit of the normal range according to age.
This report describes a spectrum of illness from SARS-CoV-2 infection in children. In contrast with infected adults, most infected children appear to have a milder clinical course. Asymptomatic infections were not uncommon.2 Determination of the transmission potential of these asymptomatic patients is important for guiding the development of measures to control the ongoing pandemic.
Notes
This letter was published on March 18, 2020, at NEJM.org.
Drs. Lu, J. Zhang, Y.Y. Li, and D. Liu and Drs. Shen, Xu, and Wong contributed equally to this letter.
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
Supplementary Material
References
1.
World Health Organization. Coronavirus disease 2019 (COVID-19): situation report — 50 (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200310-sitrep-50-covid-19.pdf?sfvrsn=55e904fb_2).
2.
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 2020 February 24 (Epub ahead of print).
3.
Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med.
4.
World Health Organization. Country & technical guidance — coronavirus disease (COVID-19) (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance).
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Published online: March 18, 2020
Published in issue: April 23, 2020
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1Wuhan Children’s Hospital, Wuhan, China
2Huazhong University of Science and Technology, Wuhan, China
3Wuhan Institute of Virology, Wuhan, China
4Huazhong University of Science and Technology, Wuhan, China
5Beijing Children’s Hospital, Beijing, China
6Wuhan Children’s Hospital, Wuhan, China
7University of California, Davis, Davis, CA
8Chinese National Clinical Research Center for Respiratory Diseases, Beijing, China
9Institute of Maternal and Child Health, Wuhan, China
10Wuhan Children’s Hospital, Wuhan, China
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11Chinese University of Hong Kong, Shatin, China
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