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To the Editor We read with interest the review by Castagnoli et al1 summarizing case series of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in 1065 children. The authors report the evidence up to March 3, 2020, and conclude that children with coronavirus disease 2019 (COVID-19) present mostly with mild symptoms, requiring supportive care only, and that no deaths had been reported in the age group younger than 9 years and 1 death in the age group 10 to 19 years. However, such short-term conclusions on an emerging disease where there are limited data available can be precarious. Evidence published since sheds more light on the spectrum of disease and the severity of COVID-19 in children.
For example, a preliminary description of pediatric COVID-19 cases (n = 2572)2 from the US Centers for Disease Control (CDC) between February 12, 2020, and April 2, 2020, showed that 20% received inpatient treatment and 2% required admission to the intensive care unit.2 Further studies report severe and critical cases of children with COVID-19 in up to 11% in the age group of younger than 1 year,3 with requirement of mechanical ventilation.
In the CDC report, 3 patients (age not specified) with confirmed SARS-CoV-2 infection had died, with confirmation of cause of death pending. Other reports state 3 deaths in children in China (neonate, aged 10 months, and aged 14 years)3-5 and as of April 25, 2020, national surveillance systems state 2 deaths in Spain (<2 years), 2 in Italy (<9 years), and 1 in Germany (age not specified). Additionally, several deaths in older children have been reported in the media from Belgium, France, Portugal, and the United Kingdom. Furthermore, an ongoing multinational multicenter study in children with COVID-19 conducted by the Paediatric Tuberculosis Network European Trials Group (ptbnet) has captured 4 children with fatal outcome to date (Florian Goetzinger, MD, written communication, April 25, 2020). This confirms that most COVID-19 cases in children are not severe, but severe courses including death can occur in all pediatric age ranges.
While in adults, older age, male sex, cardiovascular disease, hypertension, and chronic respiratory disease have all been associated with severe disease, no definite risk groups have been identified in children. However, children with chronic lung disease (including asthma), cardiovascular disease, and immunosuppression are more often reported to require hospital admission compared with previously healthy children.2 The fact that SARS-CoV-2 can cause severe disease and death in previously healthy neonates and children stresses the need for studies on epidemiology, clinical features, and risk factors of SARS-CoV-2 infection in children.
Corresponding Author: Nicole Ritz, MD, PhD, University Children’s Hospital Basel UKBB, Spitalstrasse 33, CH-4031 Basel, Switzerland (email@example.com).
Published Online: October 26, 2020. doi:10.1001/jamapediatrics.2020.2916
Conflict of Interest Disclosures: None reported.
Zimmermann P, Goetzinger F, Ritz N. Additional Concerns Regarding Children With Coronavirus Disease 2019. JAMA Pediatr. 2020;174(12):1216. doi:10.1001/jamapediatrics.2020.2916
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