Coinfection and Other Clinical Characteristics of COVID-19 in Children Qin Wu, MD,a,p Yuhan Xing, MD,b,p Lei Shi, MB,a,p Wenjie Li, MS,a Yang Gao, MS,a Silin Pan, PhD, MD,a Ying Wang, MS,c Wendi Wang, MS,a Quansheng Xing, PhD, MDa BACKGROUND AND OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is abstract a newly identified pathogen that mainly spreads by droplets. Most published studies have been focused on adult patients with coronavirus disease 2019 (COVID-19), but data concerning pediatric patients are limited. In this study, we aimed to determine epidemiological characteristics and clinical features of pediatric patients with COVID-19. METHODS: We reviewed and analyzed data on pediatric patients with laboratory-confirmed COVID-19, including basic information, epidemiological history, clinical manifestations, laboratory and radiologic findings, treatment, outcome, and follow-up results. RESULTS: A total of 74 pediatric patients with COVID-19 were included in this study. Of the 68 case patients whose epidemiological data were complete, 65 (65 of 68; 95.59%) were household contacts of adults. Cough (32.43%) and fever (27.03%) were the predominant symptoms of 44 (59.46%) symptomatic patients at onset of the illness. Abnormalities in leukocyte count were found in 23 (31.08%) children, and 10 (13.51%) children presented with abnormal lymphocyte count. Of the 34 (45.95%) patients who had nucleic acid testing results for common respiratory pathogens, 19 (51.35%) showed coinfection with other pathogens other than SARS-CoV-2. Ten (13.51%) children had real-time reverse transcription polymerase chain reaction analysis for fecal specimens, and 8 of them showed prolonged existence of SARS-CoV-2 RNA. CONCLUSIONS: Pediatric patients with COVID-19 presented with distinct epidemiological, clinical, and radiologic characteristics from adult patients. Nearly one-half of the infected children had coinfection with other common respiratory pathogens. It is not uncommon for pediatric patients to have prolonged fecal shedding of SARS-CoV-2 RNA during the convalescent phase. ’ aQingdao Women and Children’s Hospital of Qingdao University, Qingdao, China; bDepartment of Pediatrics, Faculty WHAT S KNOWN ON THIS SUBJECT: Severe acute of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; and cWuhan respiratory coronavirus 2 is a newly identified pathogen Children’s Hospital and Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China that mainly spreads by droplets. Most published studies *Contributed equally as co-first authors. have been focused on adult patients with coronavirus Drs Q. Xing, W. Wang, and Y. Wang conceptualized and designed the study, drafted the initial disease 2019, but data concerning pediatric patients are manuscript, and reviewed and revised the manuscript; Drs Wu and Y. Xing and Ms Shi limited. conceptualized and designed the study, coordinated and supervised data collection, and critically WHAT THIS STUDY ADDS: Children with coronavirus reviewed the manuscript for important intellectual content; Drs Li, Gao, and Pan designed the data disease 2019 presented with distinct clinical collection instruments, collected data, conducted the initial analyses, and reviewed and revised the characteristics from adult patients. Notably, coinfection manuscript; and all authors approved the final manuscript as submitted and agree to be with other respiratory pathogens were common in accountable for all aspects of the work. pediatric patients, highlighting the importance for the DOI: https://doi.org/10.1542/peds.2020-0961 screening of severe acute respiratory syndrome Accepted for publication May 1, 2020 coronavirus 2. Address correspondence to Quansheng Xing, PhD, MD, Department of Paediatrics, Qingdao Women and Children’s Hospital of Qingdao University, No. 6 Tongfu Rd, Qingdao 266034, China. To cite: Wu Q, Xing Y, Shi L, et al. Coinfection and E-mail: [email protected] Other Clinical Characteristics of COVID-19 in Children. Pediatrics. 2020;146(1):e20200961 Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number 1, July 2020:e20200961 ARTICLE During the last 3 months, we faced age, weight, time of onset, time of mild pneumonia, severe pneumonia, the fast-growing outbreak of diagnosis by SARS-CoV-2 nucleic and critical cases (acute respiratory coronavirus disease 2019 (COVID-19) acid test, and date of admission distress syndrome and severe acute that swept through China and rapidly and discharge), epidemiological respiratory syndrome [SARS]). Mild spread to all over the world. The history, clinical manifestations, pneumonia was further subgrouped etiologic agent, severe acute laboratory and radiologic findings, into subclinical type and clinical type respiratory syndrome coronavirus 2 treatment, outcome, and follow- on the basis of the clinical (SARS-CoV-2), was identified as up data were recorded with manifestations. a novel pathogen highly contagious to standardized data collection forms. the general population, with This study was approved by the Statistical Analysis a relatively high mortality rate. By the institutional review board of the Categorical data were expressed as end of April 2020, .3 million ethics committee of the Qingdao a number and percentage, and confirmed cases of COVID-19 were Women and Children’s Hospital continuous data were expressed reported in over 200 countries and (QFELL-KY-2020-11), and written as a median with a range or regions globally, causing .200 000 informed consent was obtained from interquartile. Statistical analyses were 1 deaths. Currently, the epidemic patients’ legal guardians before performed by using SAS software (SAS center has been shifted to the United enrollment. 9.4; SAS Institute, Inc, Cary, NC). States and Europe. In early studies on COVID-19, Chinese researchers2–5 Determination of Exposure History Role of the Funding Source fi have provided rst-hand knowledge Detailed epidemiological data of all The funder of the study had no and valuable treatment experiences case patients were collected and role in study design, data collection, fi for other countries to learn from, but classi ed according to whether the data analysis, data interpretation, most of the studies were targeted at case patients were household or writing of this article. The fi adult patients. The majority of contacts of con rmed adult patients, corresponding authors had full publication on pediatric cases of the sequence of infection within the access to all the data in the COVID-19 during the early stage of families, and whether the infected study and had final responsibility the disease were case reports or children transmitted the virus to for the decision to submit for studies with a relatively small sample others. publication. size.6–11 To determine the spectrum fi of the disease in children, we Laboratory Con rmation collected and analyzed Confirmation of COVID-19 was based RESULTS epidemiological, clinical, laboratory, on a positive result for real-time Basic Characteristics and radiologic data of 74 pediatric reverse transcription polymerase COVID-19 cases in 2 locations of chain reaction (RT-PCR) testing of None of the 74 infected children had northern and southern China. We SARS-CoV-2 in nasopharyngeal comorbidities. Detailed data of the hope our study will be used to swabs by hospital laboratory and baseline characteristics of the further the understanding of SARS- was double confirmed by the local patients are listed in Table 2, and CoV-2 infection in children and Centers for Disease Control and the time line of disease progression provide an insight to treatment Prevention using the same RT-PCR including the date of admission, strategies and prophylactic control protocol. A final decision on COVID- diagnosis, and discharge and the of the disease. 19 diagnosis was made according to final date of follow-up are shown World Health Organization interim in Fig 1. guidance.12 METHODS Epidemiological Characteristics fi Diagnosis Classi cation Complete information of exposure Data Sources According to the experts’ consensus history was collected from 68 of From January 20 to February 27 of statement on the diagnosis, the 74 patients (91.9%). Except for 2020, we retrospectively reviewed treatment, and prevention of 2019 3 sporadic cases, 65 (65 of 68; electronic medical records of 74 novel coronavirus infection in 95.6%) case patients were pediatric COVID-19 cases admitted in children issued by the Group of household contacts of adults whose the Qingdao Women and Children’s Respirology of the Chinese symptoms developed earlier and Hospital and Wuhan Children’s Pediatric Society,13 patients were the last confirmed case within the Hospital, including data recorded classified into 5 types (Table 1): family, including 18 (27.7%) being during hospitalization and the follow- asymptomatic infection, acute the second infected family member, up period. Baseline information (sex, upper respiratory tract infection, 23 (35.4%) being the third, 14 Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 WU et al TABLE 1 Definitions of Clinical Types of COVID-19 in Children Diagnostic Criteria Asymptomatic infection Positive RT-PCR test results for SARS-CoV-2 Without manifestations of clinical symptoms Without abnormal chest imaging findings Acute upper respiratory tract Upper respiratory symptoms (eg, fever, cough, pharyngeal pain, nasal congestion, fatigue, headache, and myalgia)