T h e n e w e ng l a n d j o u r na l o f m e dic i n e

C or r e sp ondence

SARS-CoV-2 Infection in Children
To the Editor: As of March 10, 2020, the 2019
novel coronavirus (SARS-CoV-2) has been responsible for more than 110,000 infections and4000 deaths worldwide, but data regarding theepidemiologic characteristics and clinical features of infected children are limited.1-3 A recent
review of 72,314 cases by the Chinese Center for
Disease Control and Prevention showed that lessthan 1% of the cases were in children younger
than 10 years of age.2 In order to determine thespectrum of disease in children, we evaluatedchildren infected with SARS-CoV-2 and treatedat the Wuhan Children’s Hospital, the only centerassigned by the central government for treating
infected children under 16 years of age in Wuhan.
Both symptomatic and asymptomatic children
with known contact with persons having confirmed or suspected SARS-CoV-2 infection wereevaluated. Nasopharyngeal or throat swabs wereobtained for detection of SARS-CoV-2 RNA byestablished methods.4 The clinical outcomes weremonitored up to March 8, 2020.
Of the 1391 children assessed and tested fromJanuary 28 through February 26, 2020, a total of
171 (12.3%) were confirmed to have SARS-CoV-2
infection. Demographic data and clinical featuresare summarized in Table 1. (Details of the laboratory and radiologic findings are provided in theSupplementary Appendix, available with the fulltext of this letter at NEJM.org.) The median ageof the infected children was 6.7 years. Fever waspresent in 41.5% of the children at any time during the illness. Other common signs and symptoms included cough and pharyngeal erythema.
A total of 27 patients (15.8%) did not have any
symptoms of infection or radiologic features ofpneumonia. A total of 12 patients had radiologic features of pneumonia but did not have any
symptoms of infection. During the course ofhospitalization, 3 patients required intensive care
support and invasive mechanical ventilation; all
had coexisting conditions (hydronephrosis, leukemia [for which the patient was receiving maintenance chemotherapy], and intussusception).
Lymphopenia (lymphocyte count, <1.2×109 perliter) was present in 6 patients (3.5%). The most

Table 1. Epidemiologic Characteristics, Clinical Features, and Radiologic Findings of 171 Children with SARS-CoV-2
Infection.*
CharacteristicValue

AgeMedian (range)

6.7 yr (1 day–15 yr)

Distribution — no. (%)<1 yr

31 (18.1)

1–5 yr40 (23.4)

6–10 yr58 (33.9)

11–15 yr42 (24.6)

Sex — no. (%)
Male

104 (60.8)

Female67 (39.2)

Diagnosis — no. (%)
Asymptomatic infection

27 (15.8)

Upper respiratory tract infection

33 (19.3)

Pneumonia

111 (64.9)

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T h e n e w e ng l a n d j o u r na l o f m e dic i n eTable 1. (Continued)
Characteristic

Value

Exposure or contact information — no. (%)
Family cluster

154 (90.1)

Confirmed family members

131 (76.6)

Suspected family members

23 (13.5)

Unidentified source of infection

15 (8.8)

Contact with other suspected case

2 (1.2)

Signs and symptoms
Cough — no. (%)

83 (48.5)

Pharyngeal erythema — no. (%)

79 (46.2)

Fever — no. (%)

71 (41.5)

Median duration of fever (range) — days

3 (1–16)

Highest temperature during hospitalization — no. (%)<37.5°C

100 (58.5)

37.5–38.0°C

16 (9.4)

38.1–39.0°C

39 (22.8)>39.0°C

16 (9.4)

Diarrhea — no. (%)

15 (8.8)

Fatigue — no. (%)

13 (7.6)

Rhinorrhea — no. (%)

13 (7.6)

Vomiting — no. (%)

11 (6.4)

Nasal congestion — no. (%)

9 (5.3)

Tachypnea on admission — no. (%)†

49 (28.7)

Tachycardia on admission — no. (%)‡

72 (42.1)

Oxygen saturation <92% during period of hospitalization — no. (%)

4 (2.3)

Abnormalities on computed tomography of the chest — no. (%)
Ground-glass opacity

56 (32.7)

Local patchy shadowing

32 (18.7)

Bilateral patchy shadowing

21 (12.3)

Interstitial abnormalities

2 (1.2)*	Percentages may not total 100 because of rounding.
†	The normal ranges of respiratory rate (in breaths per minute) were as follows: 40 to 60 for newborns, 30 to 40 for children younger than 1 year of age, 25 to 30 for those 1 to 3 years of age, 20 to 25 for those 4 to 7 years of age, 18 to 20
for those 8 to 14 years of age, and 12 to 20 for those older than 14 years of age. Tachypnea refers to a respiratory rate
higher than the upper limit of the normal range according to age.
‡	The normal ranges of pulse rate (in beats per minute) were as follows: 120 to 140 for newborns, 110 to 130 for children
younger than 1 year of age, 100 to 120 for those 1 to 3 years of age, 80 to 100 for those 4 to 7 years of age, 70 to 90 for
those 8 to 14 years of age, and 60 to 70 for those older than 14 years of age. Tachycardia refers to a pulse rate higher
than the upper limit of the normal range according to age.

common radiologic finding was bilateral groundglass opacity (32.7%). As of March 8, 2020, there
was one death. A 10-month-old child with intussusception had multiorgan failure and died
4 weeks after admission. A total of 21 patientswere in stable condition in the general wards,
and 149 have been discharged from the hospital.
2This report describes a spectrum of illness
from SARS-CoV-2 infection in children. In contrast with infected adults, most infected children
appear to have a milder clinical course. Asymptomatic infections were not uncommon.2 Determination of the transmission potential of these
asymptomatic patients is important for guidingn engl j med﻿﻿  nejm.org﻿

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Correspondence

the development of measures to control the on- Rona M. Silva, Ph.D.
Kent E. Pinkerton, Ph.D.
going pandemic.
Xiaoxia Lu, M.D.
Liqiong Zhang, M.D.
Hui Du, M.D.
Wuhan Children’s Hospital
Wuhan, China

Jingjing Zhang, Ph.D.
Yuan Y. Li, Ph.D.
Jingyu Qu, Ph.D.
Wenxin Zhang, Ph.D.
Youjie Wang, Ph.D.
Shuangshuang Bao, Ph.D.
Ying Li, Ph.D.
Chuansha Wu, Ph.D.
Hongxiu Liu, Ph.D.
Huazhong University of Science and Technology
Wuhan, China

Di Liu, Ph.D.
Wuhan Institute of Virology
Wuhan, ChinaJianbo Shao, M.D.
Xuehua Peng, M.D.
Huazhong University of Science and Technology
Wuhan, China

Yonghong Yang, M.D.
Beijing Children’s Hospital
Beijing, China

Zhisheng Liu, M.D.
Yun Xiang, M.D.
Furong Zhang, M.D.
Wuhan Children’s Hospital
Wuhan, China

University of California, Davis
Davis, CA

Kunling Shen, M.D.
Chinese National Clinical Research Center
for Respiratory Diseases
Beijing, China

Han Xiao, Ph.D.
Shunqing Xu, M.D., Ph.D.
Institute of Maternal and Child HealthWuhan, China

Gary W.K. Wong, M.D.
Chinese University of Hong Kong
Shatin, Chinawingkinwong@cuhk.edu.hk

for the Chinese Pediatric Novel Coronavirus
Study Team
Drs. Lu, J. Zhang, Y.Y. Li, and D. Liu and Drs. Shen, Xu, andWong contributed equally to this letter.
Disclosure forms provided by the authors are available withthe full text of this letter at NEJM.org.
This letter was published on March 18, 2020, at NEJM.org.
1. World Health Organization. Coronavirus disease 2019

(COVID-19):​situation report — 50 (https://www​.who​.int/​docs/​
default​-­source/​coronaviruse/​situation​-­reports/​20200310​-­sitrep​-­50​-­covid​-­19​.pdf?sfvrsn=55e904fb_2).
2. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak inChina: summary of a report of 72 314 cases from the ChineseCenter for Disease Control and Prevention. JAMA 2020 February
24 (Epub ahead of print).
3. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. DOI:​10.1056/
NEJMoa2002032.
4. World Health Organization. Country & technical guidance— coronavirus disease (COVID-19) (https://www​.who​.int/​emergencies/​diseases/​novel​-­coronavirus​-­2019/​technical​-­guidance).
DOI: 10.1056/NEJMc2005073
Correspondence Copyright © 2020 Massachusetts Medical Society.

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