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SARS-CoV-2 Infection in Infants Less than 90 Days Old
case-report
Author(s):
Leena B. Mithal , MD MSCI
1
,
∗∗
,
∗ ,
Kerri Z. Machut , MD
2
,
∗ ,
William J. Muller , MD, Ph.D.
1 ,
Larry K. Kociolek , MD MSCI
1
Publication date (Electronic):
18 June 2020
Journal:
The Journal of Pediatrics
Publisher:
Elsevier Inc.
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Abstract
This is a single-center US case series of 18 infants <90 days old who tested positive for SARS-CoV-2. These infants had a mild febrile illness without significant pulmonary disease. One half were hospitalized; one had bacterial urinary tract co-infection. Nasopharyngeal viral loads were notably high. Latinx ethnicity was overrepresented.
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Most cited references7
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SARS-CoV-2 Infection in Children
Xiaoxia Lu, Liqiong Zhang, Hui Du … (2020)
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. 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.
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Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020
Stephanie R Bialek, Ryan Gierke, Michelle Hughes … (2020)
On April 6, 2020, this report was posted online as an MMWR Early Release. As of April 2, 2020, the coronavirus disease 2019 (COVID-19) pandemic has resulted in >890,000 cases and >45,000 deaths worldwide, including 239,279 cases and 5,443 deaths in the United States ( 1 , 2 ). In the United States, 22% of the population is made up of infants, children, and adolescents aged * Includes infants, children, and adolescents. † Excludes 23 cases in children aged <18 years with missing report date. § Date of report available starting February 24, 2020; reported cases include any with onset on or after February 12, 2020. The figure is a combination epidemiological curve and line graph showing 2,549 cases of COVID-19 in children aged <18 years in the United States, by date reported to CDC during February 24–April 2, 2020. Among all 2,572 COVID-19 cases in children aged <18 years, the median age was 11 years (range 0–17 years). Nearly one third of reported pediatric cases (813; 32%) occurred in children aged 15–17 years, followed by those in children aged 10–14 years (682; 27%). Among younger children, 398 (15%) occurred in children aged <1 year, 291 (11%) in children aged 1–4 years, and 388 (15%) in children aged 5–9 years. Among 2,490 pediatric COVID-19 cases for which sex was known, 1,408 (57%) occurred in males; among cases in adults aged ≥18 years for which sex was known, 53% (75,450 of 143,414) were in males. Among 184 (7.2%) cases in children aged <18 years with known exposure information, 16 (9%) were associated with travel and 168 (91%) had exposure to a COVID-19 patient in the household or community. Data on signs and symptoms of COVID-19 were available for 291 of 2,572 (11%) pediatric cases and 10,944 of 113,985 (9.6%) cases among adults aged 18–64 years (Table). Whereas fever (subjective or documented), cough, and shortness of breath were commonly reported among adult patients aged 18–64 years (93% reported at least one of these), these signs and symptoms were less frequently reported among pediatric patients (73%). Among those with known information on each symptom, 56% of pediatric patients reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43%, respectively, reporting these signs and symptoms among patients aged 18–64 years. Myalgia, sore throat, headache, and diarrhea were also less commonly reported by pediatric patients. Fifty-three (68%) of the 78 pediatric cases reported not to have fever, cough, or shortness of breath had no symptoms reported, but could not be classified as asymptomatic because of incomplete symptom information. One (1.3%) additional pediatric patient with a positive test result for SARS-CoV-2 was reported to be asymptomatic. TABLE Signs and symptoms among 291 pediatric (age <18 years) and 10,944 adult (age 18–64 years) patients* with laboratory-confirmed COVID-19 — United States, February 12–April 2, 2020 Sign/Symptom No. (%) with sign/symptom Pediatric Adult Fever, cough, or shortness of breath† 213 (73) 10,167 (93) Fever§ 163 (56) 7,794 (71) Cough 158 (54) 8,775 (80) Shortness of breath 39 (13) 4,674 (43) Myalgia 66 (23) 6,713 (61) Runny nose¶ 21 (7.2) 757 (6.9) Sore throat 71 (24) 3,795 (35) Headache 81 (28) 6,335 (58) Nausea/Vomiting 31 (11) 1,746 (16) Abdominal pain¶ 17 (5.8) 1,329 (12) Diarrhea 37 (13) 3,353 (31) *Cases were included in the denominator if they had a known symptom status for fever, cough, shortness of breath, nausea/vomiting, and diarrhea. Total number of patients by age group: <18 years (N = 2,572), 18–64 years (N = 113,985). † Includes all cases with one or more of these symptoms. § Patients were included if they had information for either measured or subjective fever variables and were considered to have a fever if “yes” was indicated for either variable. ¶ Runny nose and abdominal pain were less frequently completed than other symptoms; therefore, percentages with these symptoms are likely underestimates. Information on hospitalization status was available for 745 (29%) cases in children aged <18 years and 35,061 (31%) cases in adults aged 18–64 years. Among children with COVID-19, 147 (estimated range = 5.7%–20%) were reported to be hospitalized, with 15 (0.58%–2.0%) admitted to an ICU (Figure 2). Among adults aged 18–64 years, the percentages of patients who were hospitalized (10%–33%), including those admitted to an ICU (1.4%–4.5%), were higher. Children aged <1 year accounted for the highest percentage (15%–62%) of hospitalization among pediatric patients with COVID-19. Among 95 children aged <1 year with known hospitalization status, 59 (62%) were hospitalized, including five who were admitted to an ICU. The percentage of patients hospitalized among those aged 1–17 years was lower (estimated range = 4.1%–14%), with little variation among age groups (Figure 2). FIGURE 2 COVID-19 cases among children* aged <18 years, among those with known hospitalization status (N = 745),† by age group and hospitalization status — United States, February 12–April 2, 2020 Abbreviation: ICU = intensive care unit. * Includes infants, children, and adolescents. † Number of children missing hospitalization status by age group: <1 year (303 of 398; 76%); 1–4 years (189 of 291; 65%); 5–9 years (275 of 388; 71%); 10–14 years (466 of 682; 68%); 15–17 years (594 of 813; 73%). The figure is a bar chart showing 745 U.S. COVID-19 cases among children aged <18 years with known hospitalization status, by age group and hospitalization status during February 12–April 2, 2020. Among 345 pediatric cases with information on underlying conditions, 80 (23%) had at least one underlying condition. The most common underlying conditions were chronic lung disease (including asthma) (40), cardiovascular disease (25), and immunosuppression (10). Among the 295 pediatric cases for which information on both hospitalization status and underlying medical conditions was available, 28 of 37 (77%) hospitalized patients, including all six patients admitted to an ICU, had one or more underlying medical condition; among 258 patients who were not hospitalized, 30 (12%) patients had underlying conditions. Three deaths were reported among the pediatric cases included in this analysis; however, review of these cases is ongoing to confirm COVID-19 as the likely cause of death. Discussion Among 149,082 U.S. cases of COVID-19 reported as of April 2, 2020, for which age was known, 2,572 (1.7%) occurred in patients aged <18 years. In comparison, persons aged <18 years account for 22% of the U.S. population ( 3 ). Although infants <1 year accounted for 15% of pediatric COVID-19 cases, they remain underrepresented among COVID-19 cases in patients of all ages (393 of 149,082; 0.27%) compared with the percentage of the U.S. population aged <1 year (1.2%) ( 3 ). Relatively few pediatric COVID-19 cases were hospitalized (5.7%–20%; including 0.58%–2.0% admitted to an ICU), consistent with previous reports that COVID-19 illness often might have a mild course among younger patients ( 4 , 5 ). Hospitalization was most common among pediatric patients aged <1 year and those with underlying conditions. In addition, 73% of children for whom symptom information was known reported the characteristic COVID-19 signs and symptoms of fever, cough, or shortness of breath. These findings are largely consistent with a report on pediatric COVID-19 patients aged <16 years in China, which found that only 41.5% of pediatric patients had fever, 48.5% had cough, and 1.8% were admitted to an ICU ( 4 ). A second report suggested that although pediatric COVID-19 patients infrequently have severe outcomes, the infection might be more severe among infants ( 5 ). In the current analysis, 59 of 147 pediatric hospitalizations, including five of 15 pediatric ICU admissions, were among children aged <1 year; however, most reported U.S. cases in infants had unknown hospitalization status. In this preliminary analysis of U.S. pediatric COVID-19 cases, a majority (57%) of patients were males. Several studies have reported a majority of COVID-19 cases among males ( 4 , 9 ), and an analysis of 44,000 COVID-19 cases in patients of all ages in China reported a higher case-fatality rate among men than among women ( 10 ). However, the same report, as well as a separate analysis of 2,143 pediatric COVID-19 cases from China, detected no substantial difference in the number of cases among males and females ( 5 , 10 ). Reasons for any potential difference in COVID-19 incidence or severity between males and females are unknown. In the present analysis, the predominance of males in all pediatric age groups, including patients aged <1 year, suggests that biologic factors might play a role in any differences in COVID-19 susceptibility by sex. The findings in this report are subject to at least four limitations. First, because of the high workload associated with COVID-19 response activities on local, state, and territorial public health personnel, a majority of pediatric cases were missing data on disease symptoms, severity, or underlying conditions. Data for many variables are unlikely to be missing at random, and as such, these results must be interpreted with caution. Because of the high percentage of missing data, statistical comparisons could not be conducted. Second, because many cases occurred only days before publication of this report, the outcome for many patients is unknown, and this analysis might underestimate severity of disease or symptoms that manifested later in the course of illness. Third, COVID-19 testing practices differ across jurisdictions and might also differ across age groups. In many areas, prioritization of testing for severely ill patients likely occurs, which would result in overestimation of the percentage of patients with COVID-19 infection who are hospitalized (including those treated in an ICU) among all age groups. Finally, this analysis compares clinical characteristics of pediatric cases (persons aged <18 years) with those of cases among adults aged 18–64 years. Severe COVID-19 disease appears to be more common among adults at the high end of this age range ( 6 ), and therefore cases in young adults might be more similar to those among children than suggested by the current analysis. As the number of COVID-19 cases continues to increase in many parts of the United States, it will be important to adapt COVID-19 surveillance strategies to maintain collection of critical case information without overburdening jurisdiction health departments. National surveillance will increasingly be complemented by focused surveillance systems collecting comprehensive case information on a subset of cases across various health care settings. These systems will provide detailed information on the evolving COVID-19 incidence and risk factors for infection and severe disease. More systematic and detailed collection of underlying condition data among pediatric patients would be helpful to understand which children might be at highest risk for severe COVID-19 illness. This preliminary examination of characteristics of COVID-19 disease among children in the United States suggests that children do not always have fever or cough as reported signs and symptoms. Although most cases reported among children to date have not been severe, clinicians should maintain a high index of suspicion for COVID-19 infection in children and monitor for progression of illness, particularly among infants and children with underlying conditions. However, these findings must be interpreted with caution because of the high percentage of cases missing data on important characteristics. Because persons with asymptomatic and mild disease, including children, are likely playing a role in transmission and spread of COVID-19 in the community, social distancing and everyday preventive behaviors are recommended for persons of all ages to slow the spread of the virus, protect the health care system from being overloaded, and protect older adults and persons of any age with serious underlying medical conditions. Recommendations for reducing the spread of COVID-19 by staying at home and practicing strategies such as respiratory hygiene, wearing cloth face coverings when around others, and others are available on CDC’s coronavirus website at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Summary What is already known about this topic? Data from China suggest that pediatric coronavirus disease 2019 (COVID-19) cases might be less severe than cases in adults and that children (persons aged <18 years) might experience different symptoms than adults. What is added by this report? In this preliminary description of pediatric U.S. COVID-19 cases, relatively few children with COVID-19 are hospitalized, and fewer children than adults experience fever, cough, or shortness of breath. Severe outcomes have been reported in children, including three deaths. What are the implications for public health practice? Pediatric COVID-19 patients might not have fever or cough. Social distancing and everyday preventive behaviors remain important for all age groups because patients with less serious illness and those without symptoms likely play an important role in disease transmission.
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Children with Covid-19 in Pediatric Emergency Departments in Italy
Niccolò Parri, Matteo Lenge, Danilo Buonsenso (2020)
To the Editor: On February 20, 2020, the incidence of Covid-19 began to rapidly escalate in Italy. By March 25, Italy had the second highest number of Covid-19 infections worldwide and the greatest number of deaths. 1 Children younger than 18 years of age who had Covid-19 composed only 1% of the total number of patients; 11% of these children were hospitalized, and none died. 2 The Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) study involved a cohort of 100 Italian children younger than 18 years of age with Covid-19 confirmed by reverse-transcriptase–polymerase-chain-reaction testing of nasal or nasopharyngeal swabs who were assessed between March 3 and March 27 in 17 pediatric emergency departments. Here, we describe the results of the CONFIDENCE study and compare them with those from three cohorts in previously published analyses. 3-5 The median age of the children was 3.3 years (Table 1). Exposure to SARS-CoV-2 from an unknown source or from a source outside the child’s family accounted for 55% of the cases of infection. A total of 12% of the children appeared ill, and 54% had a temperature of at least 37.6°C. Common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%); the latter symptom occurred more often in children younger than 21 months of age. Fever, cough, or shortness of breath occurred in 28 of 54 of febrile patients (52%) (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). A total of 4% of the children had oxygen saturation values (as measured by pulse oximetry) of less than 95%; all these patients also had imaging evidence of lung involvement. Of the 9 patients who received respiratory support (Table S2), 6 had coexisting conditions. Laboratory and imaging findings are provided in Tables S3 and S4. According to the categories described by Dong et al., 4 21% of the patients were asymptomatic, 58% had mild disease, 19% had moderate disease, 1% had severe disease, and 1% were in critical condition (Table S5). Most of the infants presented with mild disease. Severe and critical cases were diagnosed in patients with coexisting conditions. No deaths were reported. A total of 38% of the patients were admitted to the hospital because of symptoms, irrespective of the severity of disease (Table 1). 4 Among our patients, the incidence of transmission through apparent exposure to a family cluster was lower than that in other cohorts, possibly because of the late lockdown in Italy. As compared with the other cohorts, fewer patients in our cohort had moderate-to-severe disease, possibly because chest radiography was predominantly used and chest computed tomography was rarely used. Thus, fewer cases of diagnosed (subclinical) pneumonia may have been identified. Bedside lung ultrasonography by experienced sonographers was performed in only 10% of the patients, 90% of whom received a diagnosis of lung interstitial syndrome without further radiographic imaging.
Author and article information
Contributors
Leena B. Mithal
Journal
Journal ID (nlm-ta): J Pediatr
Journal ID (iso-abbrev): J. Pediatr
Title:
The Journal of Pediatrics
Publisher:
Elsevier Inc.
ISSN
(Print):
0022-3476
ISSN
(Electronic):
1097-6833
Publication date PMC-release: 18
June
2020
Publication date
(Electronic):
18
June
2020
Affiliations
Author notes
[∗∗
]Corresponding author: Leena B. Mithal, MD MSCI Address: 225 E Chicago Avenue, Box
#20, Chicago IL 60611 Phone: 312.227.4080, Fax: 312.227.9709
lmithal@
123456luriechildrens.org
Article
Publisher ID: S0022-3476(20)30750-2DOI: 10.1016/j.jpeds.2020.06.047
PMC ID: 7301101
PubMed ID: 32565095
SO-VID: a43e7f4a-7a27-4db9-8e1f-5b89d777d54e
Copyright © © 2020 Elsevier Inc. All rights reserved.
License:
Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
History
Date
received
: 2
June
2020
Date
revision received
: 11
June
2020
Date
accepted
: 12
June
2020
Categories
Subject:
Article
ScienceOpen disciplines: Pediatrics