The Wide Spectrum of COVID-19 Clinical Presentation in Children

Abstract

Background: Ten months after its appearance in December 2019, SARS-CoV-2 has infected more than 25 million patients worldwide. Because children were first identified as potential spreaders of the virus, schools were closed in several countries. However, it rapidly became evident that the number of hospitalized children infected by SARS-CoV-2 was dramatically lower than that of adults. To date, only hypotheses have been raised to explain this difference, so it is of great importance to describe the presentation of this disease among children. Here, we describe a wide spectrum of COVID-19 manifestation in children in a dedicated pediatric unit in France. Methods: Patients hospitalized with COVID-19 who were diagnosed on the basis of either positive SARS-CoV-2 RT-PCR in nasopharyngeal swabs and/or typical aspects in chest-computed tomography (CT) were included between March and May 2020 in Paris. Results: Twenty-three patients were included on the basis of positive RT-PCR (n = 20) and/or typical aspects in CT (n = 4). The median age was 4.9 years [0.1-17.6]. Patients were grouped by age (<2 years old: n = 14, 61%; 2-10 years old: n = 2, 9%; >10 years old: n = 7, 30%). Overweight or obesity was reported in only three patients. At presentation, the most frequent symptom in the overall cohort was fever (n = 18, 78%), followed by acute rhinitis (n = 9, 64%) and cough (n = 7, 50%) in the under 2-year-old group and cough (n = 4, 57%), fatigue, dyspnea and abdominal pain (n = 3, 43% each) in the over 10-year-old group. Five patients required ICU treatment, four of whom were aged >10 years, two presented with acute myocarditis, and two were sickle cell disease patients who presented with acute chest syndrome. Discussion and conclusion: The youngest patients seem to present milder forms of COVID-19 without the need for ICU treatment and with a shorter length of hospitalization. More severe evolutions were observed in teenagers, with, however, favorable outcomes. Given the context of closed schools and confinement, the infection of these children suggests intra-familial transmission that needs to be further assessed. This description might help to understand the intriguing differences in COVID-19 severity across age-classes.

Keywords: COVID-19; MIS-C; PIMS-TS; SARS-CoV-2; acute respiratory distress syndrome; children; infants.

Figure 1

Distribution of children with COVID-19 per age-class. Among the 23 included patients, the majority (n = 14, 61%) were aged under 2 years old, only 9% (n = 2) were aged 2–10 years old, and 30% (n = 7) were over 10 years old. The red line illustrates the distribution across age-classes.

Figure 2

Graphical timeline of the clinical evolution of the 21 children with symptomatic COVID-19. Medical status was determined daily for each patient from the onset of symptoms (day 0) until discharge home and scored from 0 to 4: 1 = presence of symptoms, 2 = hospital admission, 3 = oxygen therapy, 4 = ventilatory support (non-invasive ventilation (NIV) or mechanical ventilation) and 0 = discharge. The data are the mean of the daily medical status scores in each age group (<2 years old in blue and >10 years-old in red) from the onset of symptoms. Error bars show standard deviations. As only one patient showed symptoms in the 2–10-year-old group, this age group is not represented in this figure. This figure illustrates that in the youngest patients, the disease is symptomatic at the onset but has a rapid positive outcome, whereas, in older children, the severity subsequently increases, sometimes requiring intensive care and longer hospitalizations.