Additional Concerns Regarding Children With Coronavirus Disease 2019

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 (chchiu@cgmh.org.tw).

Published Online: October 26, 2020. doi:10.1001/jamapediatrics.2020.2919

Conflict of Interest Disclosures: None reported.