Editor—The coronavirus disease 2019 (COVID-19) pandemic has led to drastic changes in the structure of clinical care worldwide.
1During the rising phase of the epidemic spread, health systems are being overwhelmed by critically ill COVID-19 patients.
2Once the peak of COVID-19 cases has passed, delayed medical and surgical care will become a priority. The high transmission rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mandated two major organisational priorities: (i) avoid nosocomial spread of COVID-19 and (ii) minimise COVID-19 disease in healthcare staff.
3Most guidelines recommend confirming the diagnosis of COVID-19 (using real-time quantitative polymerase chain reaction [RT–qPCR]) in suspected cases based on clinical symptoms and signs or previous contact with confirmed cases.
The primary objective was to describe the proportion of paediatric patients diagnosed with SARS-CoV-2 (using RT–qPCR) presenting with general, respiratory, smell and taste (anosmia and ageusia),
3or dermatological symptoms (vesicles or pustules, other vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis).
4Secondary outcomes included COVID-19 disease severity categorised as mild, moderate, severe, or critical as defined by Dong and colleagues,
- Galván Casas C.
- Català A.
- Carretero Hernández G.
- et al.
Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases.
Br J Dermatol. 2020 Apr 29; https://doi.org/10.1111/bjd.19163
5and the presence of specific radiological signs (characteristic ground glass appearance on chest CT).
This meta-analysis was registered (https://osf.io/3u8nh) and performed according to the Cochrane Handbook for Systematic Reviews of Interventions guidelines.
Bias analysis was performed using the Risk of Bias in Longitudinal Symptom Research studies tool edited by The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews: Checklist for Case Series.
Overall, 737 articles were identified, and 28 (including 1614 patients) were relevant for analyses (see Supplementary file for references). All studies but one were retrospective and included patients from China with the exception of four studies (from Malaysia, Spain, Italy, and the USA). Despite the retrospective nature of most studies, studies exhibited a low risk of bias in most of items. However, the representativeness of studies was probably biased given the absence of information about the consecutiveness of recruitment in most studies. The proportion of patients exhibiting each clinical sign, the severity of COVID-19, and CT imaging signs are displayed in Table 1. Most results exhibited high heterogeneity. Publication bias was not observed apart for asymptomatic patient outcome (Table 1).
Table 1Analysis of primary and secondary outcomes of the meta-analysis. Results are expressed as mean percentages (95% confidence interval [CI]). I2, heterogeneity of the result; P, level of significance of the heterogeneity. ∗Classification of severity was based on Dong and colleagues.
|Outcome||Number of patients included for the outcome||Number of studies included for the outcome||Percentage (95% CI)||I2 statistics (%); P for I2||Egger test (level of significance)||Begg-Mazumdar test (level of significance)|
|Asymptomatic||1600||26||16 (10; 23)||88.5; <0.0001||0.001||0.006|
|Fever||887||27||48 (42; 54)||51.2; 0.001||0.7||0.7|
|Headache||482||6||13 (4; 25)||88; <0.0001||—||—|
|Myalgia||312||3||14 (4; 29)||58.4; 0.09||—||—|
|Fatigue||372||9||8 (5; 11)||0; 0.7||—||—|
|Sneezing||19||2||23 (8; 44)||0; 0.9||—||—|
|Rhinorrhoea||741||14||16 (11; 22)||68.3; <0.0001||0.02||0.05|
|Sore throat||548||14||14 (7; 22)||76.6; <0.0001||0.7||0.06|
|Cough||837||25||40 (33; 47)||67.2; <0.0001||0.2||0.8|
|Nausea or vomiting||800||16||9 (6; 13)||50.5; 0.02||0.6||0.2|
|Diarrhoea or constipation||824||19||10 (7; 14)||40.9; 0.03||0.6||0.05|
|Abdominal pain||478||8||6 (4; 8)||0; 0.7||—||—|
|Mild infection∗||1543||23||37 (26–48)||92.7; <0.0001||0.02||0.4|
|Moderate infection∗||1543||23||45 (35–54)||88; <0.0001||0.04||0.7|
|Severe infection∗||1543||23||3 (1–5)||63.2; <0.0001||0.2||0.006|
|Critical infection∗||1543||23||0.6 (0.3–1)||0; 0.9||0.5||0.004|
|CT scan||401||17||55 (45; 64)||64.5; 0.0001||0.02||1|
Fever and cough were the most common signs of COVID-19 after SARS-CoV-2 infection in children. Our study conclusively confirmed the clinical impression that COVID-19 in children typically presents as a mild (37%) or moderate (45%) upper respiratory tract infection and is rarely severe or critical. This result is of great significance with respect to the planning of healthcare resource use over the coming months worldwide. Given that the pandemic will continue across seasons and overlap with peak influenza periods, it will be difficult to distinguish symptomatic paediatric COVID-19 patients from patients with influenza.
In our analysis, 16% of SARS-CoV-2-infected paediatric patients were asymptomatic. This proportion of asymptomatic patients is very likely a representation of RT–qPCR testing after contact. Asymptomatic patients have been estimated to represent 85% of infected patients in the general population,
8and a recent study in pregnant women found 13.5% of asymptomatic patients with a positive RT–qPCR test.
9Consequently, in the context of community SARS-CoV-2 spread, generalised population-based screening using RT–qPCR appears the most effective strategy for detecting SARS-CoV-2-infected paediatric patients with no clinical signs or known contacts.
Our results are of particular interest when considering the future management of hospitalised patients. There is a good case to be made for screening all hospital inpatients, or at least considering a strategy relying on a careful screening of patients for clinical signs or a recent contact with an infected person followed by an RT–qPCR confirmation. However, one must also keep in mind that a negative result is no guarantee of the absence of infection. Studies have shown that RT–qPCR test sensitivity averages 70% when samples were taken from the nasopharynx.
10Therefore, any patient with a high index of suspicion of COVID-19 should be treated as such in terms of protective measures, even where the RT–qPCR is negative. Radiological findings have shown promise as diagnostic tests for COVID-19 in adult patients.
In conclusion, our meta-analysis sheds light on (i) the absence of specificity regarding COVID-19 symptoms in children and (ii) the relatively high proportion of asymptomatic patients. Our results should be considered when policy is determined for detecting SARS-CoV-2 infection in children in the context of medical and surgical management.
Declarations of interest
The authors declare that they have no conflicts of interest.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
- Multimedia component 1
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- Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases.Br J Dermatol. 2020 Apr 29; https://doi.org/10.1111/bjd.19163
- Epidemiology of COVID-19 among children in China.Pediatrics. 2020; 145e20200702
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- Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2).Science. 2020; 368: 489-493
- Universal screening for SARS-CoV-2 in women admitted for delivery.N Engl J Med. 2020; 382: 2163-2164
- Positive rate of RT-PCR detection of SARS-CoV-2 infection in 4880 cases from one hospital in Wuhan, China, from Jan to Feb 2020.Clin Chim Acta. 2020; 505: 172-175
Published online: May 31, 2020
Accepted: May 19, 2020
Received: May 14, 2020
© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.