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Comment & Response
October 26, 2020

Additional Concerns Regarding Children With Coronavirus Disease 2019

Author Affiliations
  • 1Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
  • 2Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
JAMA Pediatr. 2020;174(12):1218. doi:10.1001/jamapediatrics.2020.2934

To the Editor We read with great interest the study by Castagnoli et al1 that shows milder symptoms, better prognosis, and less severe conditions in children with coronavirus disease 2019 (COVID-19) than adults. Infected children were observed to have recovered within 1 to 2 weeks after disease onset. It is refreshing to note that Castagnoli et al1 have adopted an optimistic view on the lesser predisposition to or better prognosis for COVID-19 in children than adults. However, considering the limited number of infected children in each individual study, we must hold some reservations about the generalizability of this finding.

In support of the findings by Castagnoli et al,1 we reason that it is possible that children with enhanced or trained immune memory2 are at lower risk for COVID-19, because in China, an intensive range of vaccinations is prepared for each child during the first 3 years. It is widely recognized that vaccinations can mediate the immune system into an active state through a complex interplay between innate, humoral, and cell-mediated immunity.3 However, a note of caution should be sounded for neonates (aged 0-28 weeks), because they are in a special condition of not developed or underdeveloped immune systems. We agree that more studies involving neonates with COVID-19 or suspected COVID-19 are required to confirm or refute the finding by Castagnoli et al.1

We cast doubt on the lower mortality rates of children reported by Castagnoli et al1 in light of a lower rate of mortality in children with COVID-19 in this systematic review. Yet, this systematic review focused on articles published as of March 3, 2020, reporting only 1 death in 1065 children. Following this cutoff date, articles were published showing 1 pediatric death in China (as of March 19)4 and 3 in the United States (as of April 2).5 Hence, time lag bias may have affected the findings of this review, and more concerns are warranted.

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Article Information

Corresponding Author: Qi Zhang, MD, China-Japan Friendship Hospital, No. 2 Yinghua E St, Chaoyang District, Beijing 100029, China (

Published Online: October 26, 2020. doi:10.1001/jamapediatrics.2020.2934

Conflict of Interest Disclosures: None reported.

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