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To the Editor We read with great interest the study by Castagnoli et al1 published in JAMA Pediatrics describing the clinical features of coronavirus disease 2019 (COVID-19) in children through a systemic review. We believe that the disease severity of children with COVID-19 was significantly underestimated in the study owing to a lack of crucial studies’ enrollment. Most of the cases included in this review were from reports in the early explosion stage of the COVID-19 outbreak in China; in that stage, children in Hubei province, sick or not, actually were rarely tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).2 Furthermore, the case number in children with critical or severe COVID-19 disease would not increase until the later stage of large community outbreak with an immense disease burden.2 One of the largest pediatric case series3 from the Hubei province in the stage of community outbreak demonstrated that among 171 confirmed cases, there were 8 severe/critical cases (4.6%) and 1 mortality. The case series was not included in the review.3 Severe COVID-19 in children, especially those younger than 1 year, were subsequently reported from other countries with large community outbreaks such as Japan and the United States soon after the World Health Organization declared COVID-19 as a global pandemic.4
With regards to the transmission dynamics, most of the studies showed that early in the outbreak, children usually acquired the infection in the household clusters.1,2 When the epidemic further disseminated without being efficiently contained, the outbreak evolved into an explosion stage, when the school transmission mixed with a wider community spread occurred.2 In most countries, schools were closed during this phase to prevent further intraschool or school-family transmission of the infection.2 Children can be a significant spreader of SARS-CoV-2 if the public health system does not enforce the social distancing policy for children and adolescents (school closure), given the relatively high proportion of mild/asymptomatic infection and prolonged viral shedding in children with COVID-19.5
Because the clinical evidence of COVID-19 in the pediatric population has increased rapidly in recent months, a timely systemic review is needed to reveal a more complete view on the epidemiology of COVID-19 in children and adolescents.
Corresponding Author: Cheng-Hsun Chiu, MD, PhD, Department of Pediatrics, Chang Gung Memorial Hospital, No. 5 Fu-Hsin St, Kweishan 333, Taoyuan, Taiwan (firstname.lastname@example.org).
Published Online: October 26, 2020. doi:10.1001/jamapediatrics.2020.2919
Conflict of Interest Disclosures: None reported.
Chen Y, Chiu C. Additional Concerns Regarding Children With Coronavirus Disease 2019. JAMA Pediatr. 2020;174(12):1216–1217. doi:10.1001/jamapediatrics.2020.2919
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