Reviewing: Dong Y et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020; doi: 10.1542/peds.2020-0702 (pre-publication release, peer reviewed)

Author: Fatima Al Dhaheri, MD, Fellow, Infectious Diseases, Boston Children’s Hospital

Background:

In December 2019, a cluster of cases of pneumonia of unknown origin was reported in Wuhan, China. This was subsequently etiologically attributed to a novel RNA virus of the coronavirus family that has phylogenetic similarity to severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV). Termed 2019 coronavirus disease (COVID-19) by the WHO, it has been designated as public health emergency of international concern (PHEIC). The literature has largely reported the epidemiological and clinical characteristics of COVID-19 in adult patients, and scarcely in children. This present study is the largest epidemiological case series of pediatric COVID patients to date.

Methods and Results:

This study was a nationwide case series of 2143 pediatric patients under the age of 18 diagnosed with COVID-19 in China between January 16th to February 8th, 2020. Both confirmed and suspected cases were included. Confirmed cases were defined as RT-PCR positive from nasopharyngeal swab specimens or blood samples in addition to genetic sequencing of samples that demonstrated homology with the 2019 novel coronavirus. Suspected cases were defined if a high-risk patient demonstrated two of the following: 1- Fever or respiratory or gastrointestinal symptoms or fatigue, 2- Normal or decreased total white blood cell count or increased C-reactive protein, 3-Abnormal chest x-ray. High risk status was designated for children who were exposed to a COVID-19 case while medium risk status was designated for children who lived in endemic areas or communities with reported COVID-19 cases. Low risk status was designated for children who lived in non-endemic areas where no COVID-19 cases were reported. Both medium and low risk patients were considered suspected cases of COVID-19 if they met aforementioned criteria in addition to ruling out other respiratory tract infections. Asymptomatic infection was defined as positive test while lacking clinical and radiographic findings. Mild infection was defined as presence of clinical findings with a positive test but no auscultatory findings or supporting radiographic findings. Moderate infection was defined as demonstrating a positive test with clinical findings in addition to having radiographic findings whereas severe infection was defined as both clinical and radiographic findings in addition to hypoxemia (<92%). 731 patients (34.1%) were identified as confirmed cases while 1412 (65.9%) were identified as suspected cases. Median age was 7 years old (IQ 2-13) and 56.6% were males. 94.1% of cases were designated either asymptomatic (4.4%), mild (50.9%) or moderate (38.8%) infection. Proportion of severe and critical cases by age group for <1yr was 10.6 %, 1-5yr: 7.3%, 6-10yr: 4.2%, 11-15yr: 4.1% and >16yr: 3.0%. There was only one death reported in the entire cohort (14-year-old male).

Critique:

Albeit being the largest epidemiological study on pediatric patients to date, this study has several limitations. The inclusion of suspected cases of COVID-19 without confirmatory testing will affect specificity as these cases might be secondary to other respiratory viral illnesses. The study also lacked more granular data pertaining to clinical characteristics, laboratory and radiographic findings. Finally, the study also did not report exposure history and subsequently was not able to assess incubation period.

Conclusions:

While it did lack more granularity, this study did showcase that pediatric patients in comparison to adult patients tend to develop a milder manifestation of the disease. However, an important finding this study reported was that pediatric patients who develop severe disease tend to be in the younger age groups (Highest proportion of severe and critical cases were in those aged <1). This highlights a more vulnerable at-risk group within the pediatric population.

References:

Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020; doi: 10.1542/peds.2020-0702