European Review for Medical and Pharmacological Sciences

2021; 25: 1146-1157

Epidemiological features of coronavirus disease2019 in children: a meta-analysis
J.-G. WANG1, Z.-J. ZHONG2, Y.-F. MO3, L.-C. WANG1, R. CHEN1Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
3
Liuzhou Workers’ Hospital, Liuzhou, Guangxi, China
1
2

JI-Gan Wang, Zhi-Juan Zhong and Yu-Fang Mo contributed equally to this work

Abstract. – OBJECTIVE: Many studies havebeen published recently on the characteristicsof the clinical manifestations of COVID-19 in children. The quality scores of literature are different, and the incidence of clinical manifestations
and laboratory tests results vary greatly. Therefore, a systematic retrospective meta-analysis isneeded to determine the incidence of the clinicalmanifestations of COVID-19 in children.
MATERIALS AND METHODS: Data from databases, such as PubMed, Web of science, EMBASE, Johns Hopkins University, and Chinese
databases were analysed from January 31, 2020
to October 20, 2020. High-quality articles wereselected for analysis based on a quality standard score. A meta-analysis of random effects
was used to determine the prevalence of comorbidities and subgroup meta-analysis to examine
the changes in the estimated prevalence in different subgroups.
RESULTS: Seventy-one articles involving
11,671 children were included in the study. The
incidence of fever, respiratory symptoms, gastrointestinal symptoms, asymptomatic patients,
nervous system symptoms, and chest tightness
was 55.8%, 56.8%, 14.4%, 21.1%, 6.7%, and 6.1%,
respectively. The incidence of multisystem inflammatory syndrome was 6.2%. Laboratory examination results showed that lymphocyte decreased in 12% and leukocytes decreased in
8.8% of patients, whereas white blood cells increased in 7.8% of patients. Imaging showed abnormalities in 66.5%, and ground-glass opacities were observed in 36.9% patients. Epidemiological history was present in 85.2% cases; severe disease rate was 3.33%. The mortality rate
was 0.28%.
CONCLUSIONS: The clinical symptoms of
COVID-19 in children are mild, and laboratory indicators and imaging manifestations are atypical. While screening children for COVID-19, in
addition to assessing patients for symptoms as
the first step of screening, the epidemiologicalhistory of patients should be obtained.
1146

Key Words:
2019-nCoV, COVID-19, SARS-CoV-2, Coronavirus
disease 2019, Children.

Introduction
The emergence of coronavirus disease 2019
(COVID-19) was first reported at the end of 2019.
The disease rapidly spread worldwide in a few
months and was declared a global pandemic by
WHO in March 20201. In the early stage of theepidemic, the reported number of children who
were infected was relatively small, and children
were considered not to be easily infected2. However, as time progressed, people began to pay attention to the rising number of cases in children3,4
with a few reports of severe cases5. In most adultpatients, the clinical manifestations included fever, cough, and fatigue, while most of the patients
who died were middle-aged and elderly patientswith more than one chronic underlying disease,such as cardiovascular or cerebrovascular disease or diabetes. It was reported that the longer
it took to diagnose COVID-19 (more than 5 days
from onset to diagnosis time), the higher therisk of death6. In adult patients with COVID-19,
laboratory tests showed leukopenia, especiallylymphopenia, and imaging tests showed groundglass opacities7. Most children had relatively mild
clinical symptoms. Common clinical manifestations in children included fever, dry cough,and fatigue and only a few children had upper
respiratory symptoms, such as nasal congestion,
runny nose, and sore throat. Some infected newborns and children had atypical symptoms, suchas gastrointestinal problems including vomiting,diarrhoea, or only poor appetite and shortness ofCorresponding Author: Ji-gan Wang, MD; e-mail: 354713144@qq.com
ORCID ID: 0000-0001-7775-3308

Epidemiological features of coronavirus disease 2019 in children: a meta-analysis

breath8. Laboratory and imaging tests in children
were less sensitive and less specific than that inadults9. Our study, therefore, aimed to identify
the clinical features of children with COVID-19
in order to help clinicians diagnose children
suspected of having COVID-19 more easily andtreat them.

Materials and Methods
Guidelines and RegistryThis study is reported in accordance withthe 2009 guidelines of the Preferred Reporting
Items for Systematic Reviews and Meta-analyses(PRISMA) statement (Supplementary Table I
PRISMA Checklist). This systematic review andmeta-analysis was registered in PROSPERO-The
International Prospective Register of Systemic
Reviews (CRD42020202211).
Data Collection
Computer retrieval of data from PubMed, EMBASE, Web of Science, Johns Hopkins University
published data, as well as data from Chinese database CNKI, Wanfang, Chongqing Weipu data
was conducted to collect literature reporting thecharacteristics of COVID-19 positive children.
The retrieval time for data was from January 31,
2020, to October 20, 2020. Simultaneously, online database retrieval and manual retrieval wereconducted, and the references included in the literature were also traced. Subject words and freewords were used in the retrieval, and adjustments
were made according to the characteristics of different databases. Data retrieval was not limited to
any language or country. For the PubMed searchstrategy, three search categories were used in
combination as follows:#1 AND #2 AND #3, where #1 = (children)
OR (child) OR (kid) OR (paediatric), #2 = (clinical feature) OR (epidemiology) OR (characteristics), and #3 = (2019-nCoV) OR (COVID-19) OR(SARS-CoV-2) OR (Corona Virus Disease 2019).
Literature Screening andData Extraction
Two researchers independently searched andscreened the literature, collected and crosschecked the data. If there was any dispute, it was
discussed and clarified with consultation from thethird researcher.
The inclusion criteria were as follows: (1)study type: cohort study, case-control study,

and case analysis; (2) participants: children diagnosed with COVID-19; (3) observation index: the clinical manifestations of the patients
included fever, cough, asymptomatic patients,
imaging laboratory examination, severe cases,
and deaths.
The exclusion criteria were as follows: (1) research without child description; (2) short casereports; (3) incomplete or missing analysis data
and where no data could be obtained by contacting authors.
Quality Evaluation of the
Included Studies
This retrospective study adhered to the National Institute for Clinical excellence guidelines for
quality evaluation. The evaluation items were as
follows: (1) in the case series, cases from medical institutions of different levels and various
research centres were included; (2) the research
hypothesis or purpose was clearly stated; (3) clear
reports were included in the exclusion criteria; (4)measurements were clearly defined; (5) the collected data achieved the expected purpose; (6) patient recruitment period was clearly defined; (7)the main findings were clearly described, and (8)results were analysed and reported in layers. One
point was awarded for each item (maximum 8
points), and a total score ≥4 indicating high-quality research10. Two researchers independently
evaluated the quality and cross-checked the results.
Statistical Analysis
Statistical analyses were conducted using theMeta 4.11-0 Package in R Software Version
3.6.3. Before meta-analysis, the conversion of
the original rate that conforms to a normal distribution was carried out first. The meta-analysis
was carried out on the normal distribution ormode closest to the state distribution. A randomor fixed-effects model was selected according
to heterogeneity: if p>0.1 and I2≤50%, a fixedmodel was used, and if p<0.1 and I2>50%, thestudy was considered to have heterogeneity, anda random-effects model was used. According
to the sample size of each independent study,
different weightage was given, and the effective
rate of each independent sample was combined
to calculate the incidence rate and 95% confidence interval (CI). To explore heterogeneity,
we performed subgroup analyses based on thelocation (region) and sample size (<50, ≥50).
1147

J.-G. Wang, Z.-J. Zhong, Y.-F. Mo, L.-C. Wang, R. Chen

Finally, a funnel graph was made, and the publication offset was statistically tested using the
Egger method.
EthicsAs this is a systematic review, ethical approval
was not required.

Results
Literature Screening Process and Results
A total of 2,742 relevant studies were initiallyselected. Subsequently 1,359 duplicates were deleted from these, and out of the remaining, 1,162
were deleted after reading titles and abstracts. A
total of 71 studies11-81 were selected after careful
screening. The included studies involved 11,671
paediatric patients. The male to female ratio was
1.14:1. The literature screening process and results are shown in Figure 1. The characteristicsof the included studies are shown in Supplementary Table II.

Figure 1. The flowchart of study selection.

1148

Basic Characteristics andQuality Evaluation Results of
the Included Studies
The quality characteristics of included studies
were 4-8 points, indicating they were high-quality studies (≥4 points; Supplementary Table III).
Meta-Analysis Results
The meta-analysis results have been reported
in detail in Table I.
Clinical Manifestations
The incidence of fever, respiratory symptoms, gastrointestinal symptoms, asymptomaticpatients, nervous system symptoms, and chest
tightness was 55.8% (50.3%-61.3%), 56.8%(95%CI: 0.9%-62.5%), 14.4% (11.8%-17.2%),
21.1% (16.9%-25.8%), 6.7% (4.6%-9.2%), and6.1% (3.9%-8.6%), respectively. The incidenceof multisystem inflammatory syndrome (MIS-C)
was 6.2% (2.8%-10.7%).

Epidemiological features of coronavirus disease 2019 in children: a meta-analysis
Table I. Meta-analysis results.
						
Outcome indicators

Number			 Heterogeneity			of					Effectincluded Sample				ofstudiessize
p-values
I2
t2
model

Clinical feature							Asymptomatic
49	  7664< 0.01
0.027
92.7%
RandomFever68	  7153< 0.01
0.046
94.8%
RandomRespiratory symptoms
66	  6758< 0.010.050
95.0%
RandomGastrointestinal symptoms
60	  6817< 0.01
0.016
87.3%
RandomNeurological symptoms
45	  5792< 0.01
0.018
89.7%
RandomChest pain, chest tightness
47	  4999< 0.01
0.022
89.4%
Randomand Fatigue
Laboratory results							Leukocytosis
28	  1099< 0.01
0.022
76.3%
Random
Leukopenia
32	  1606< 0.01
0.027
83.9%
RandomLymphocytosis
35	  2473< 0.01
0.045
92.2%
Random
CRP
27	  1033< 0.01
0.049
87.7%
RandomESR	  8	   254
< 0.01
0.132
94.1%
Random
D - dimer
15	   769
< 0.01
0.013
70.5%
Random
PCT18	   902
< 0.01
0.092
94.4%
Random
LDH
16	   646
< 0.01
0.048
87.4%
RandomIL-6	  6	   320
< 0.01
0.019
75.4%
Random
TNF-α	  4	   255
0.04
0.190
39.0%
Fixed
IFN-γ
v3	   231
0.04
0.013
68.3%
Random
ALT22	  1080< 0.01
0.026
83.2%
Random
CK-MB22	  1197< 0.01
0.067
93.3%
RandomFerritin	  5	   158
< 0.01
0.035
78.8%
RandomBUN,
12	  2114
0.03
0.020
49.7%
Fixed
Cr
12	  2136< 0.010.040
63.0%
Random
MIS-C
10	  2246< 0.010.014
92.0%
RandomImaging examination							Imaging abnormality
41	  1678< 0.01
0.029
82.4%
RandomGGO
35	  1407< 0.01
0.028
81.7%
RandomOther results							Epidemiological exposure50	  3147< 0.01
0.056
93.1%
RandomSevere case6310340
< 0.01
0.019
91.6%
RandomMortality
67
11309
0.05
0
22.7%
Fixed

Meta-analysis results
R% (95% CI)
21.1% (16.9%-25.8%)
55.8% (50.3-61.3%)
56.8% (50.9%-62.5%)
14.4% (11.8%-17.2%)
6.7% (4.6%-9.2%)
6.1% (3.9%-8.6%)
7.8% (4.6%-11.8%)
8.8% (5.4%-13.0%)
12.0% (7.4%-17.5%)
22.2% (15.0%-30.5%)
20.5% (4.3%-44.6%)
11.4% (7.1%-16.7%)
17.5% (7.8%-30%)
32.3% (21.7%-44.0%)
11.0% (4.1%-20.6%)
4.4% (2.2%-7.5%)
5.0% (2.6-8.2%)
6.9% (3.5%-11.5%)
13.5% (6.6%-22.4%)
5.6% (0.2%-17.6%)
1.2% (0.8%-1.7%)
1.6% (0.6%-3.2%)
6.2% (2.8-10.7%)
66.5% (60.5%-72.2%)
36.9% (30.6%-43.4%)
85.2% (79.8%-89.9%)
3.33% (2.03%-4.94%)
0.28% (0.19%-0.39%)

Abbreviations: ALT, alanine aminotransferase; CK-MB, creatine kinase-MB; CRP, C-reactive protein; LDH, lactate dehydrogenase;
MIS-C multisystem inflammatory syndrome in children; IL-6, interleukin-6; PCT, Procalcitonin; ESR, Erythrocyte sedimentation
rate; TNF-α,tumor necrosis factor α; IFN-γ, Interferon γ; Blood urea nitrogen; Cr, creatinine; GGO, Ground-glass opacities.

Laboratory Examinations
Lymphocyte count decreased in 12% (7.4%17.5%) and leukocyte count decreased in 8.8%
(5.4%-13.0%) patients. The white blood cellcount increased in 7.8% (4.6%-11.8%) patients.
Other markers such as alanine aminotransfease(ALT) 6.9% (3.5%-11.5%), creatine kinase-MB(CK-MB) 13.5% (6.6%-22.4%), blood urea nitrogen (BUN )1.2% (0.8%-1.7%), and creatinine(Cr) 1.6% (0.6%-3.2%) were also elevated. Elevated inflammatory markers C-reactive protein(CRP), ferritin, lactate dehydrogenase (LDH),
interleukin-6, Procalcitonin (PCT), D-dimer, Interferon-γ (IFN-γ), and tumor necrosis factor-α(TNF-α), Erythrocyte sedimentation rate (ESR),

were 22.2% (15.0%-30.5%), 5.6% (0.2%-17.6%),
32.3% (21.7%-44.0%), 11.0% (7.1%-16.7%),
17.5% (7.8%-30%), 11.4% (7.1%-16.7%), 5.0%
(2.6-8.2%), 4.4% (2.2%-7.5%), and 20.5% (4.3%44.6%), respectively.
Imaging
Imaging abnormality rate was 66.5% (60.5%72.2%), and ground-glass appearance was present
in 36.9% (30.6%-43.4%) of cases.
Severe Cases and Mortality Rates
Of the included patients, 3.33% (2.03%-4.94%)
were severe cases. The mortality rate was 0.28%(0.19%-0.39%).
1149

J.-G. Wang, Z.-J. Zhong, Y.-F. Mo, L.-C. Wang, R. Chen

Subgroup Analysis
In this study, except for mortality rates, otherfactors had apparent heterogeneity (I2, 49.7%95.0%). To explore the source of heterogeneity,
the subjects were classified according to country(China, United States, Europe, and other countries) and sample size (<50, or ≥50), and further
grouped by individual symptoms, such as fever,gastrointestinal symptoms, respiratory symptoms, and asymptomatic cases. The subgroup
analysis results were consistent with the overall
results, and there was no significant difference
between the heterogeneity of each subgroup andoverall heterogeneity, indicating that the regionand sample size of the study were not the primarysources of heterogeneity (Table II).
Sensitivity Analysis
We performed a sensitivity analysis to investigate the influence of each individual study on
the overall summary odds ratio by omitting eachstudy turn by turn and re-estimating the sum-mary odds ratio. The results did not change significantly, indicating that the observations wererelatively stable (Figure 2).
Publication Bias
The meta-analysis of the observed indicators of
the number of patients with fever produced funnel plots, and the results showed that the distribution of the left and right distribution symmetry
was not good (Figure 3). The p-values checked by
Egger’s regression test were 0.013, indicating thatpublication bias may exist.

Discussion
Clinical Manifestations
Based on the clinical characteristics of the existing paediatric cases, children with COVID-19
can be divided into five clinical types: asymptomatic, mild, common, severe, and critically severe infections8. Most COVID-19 positive

Table II. Results of subgroup analysis.
						
Outcome indicators

Number			 Heterogeneity			of					Effectincluded Sample				ofstudiessize
p-values
I2
t2
model

Meta-analysis results
R% (95% CI)

Fever							
China
33
1349
< 0.0169.1%
0.015 Random
48.6% (43.2%-54.2%)
US
10
2535
< 0.0197.8%
0.059 Random
59.5% (43.9%-74.1%)
Europe15
1851< 0.0195.7%
0.05 Random
60.4% (48.7%-71.5%)
other countries	  81023< 0.0195.9%
0.07 Random
70.1% (51.4%- 85.9%)
N < 5039	  867< 0.01
78.1%
0.04 Random
59.7% (52.4%-66.7%)
N ≥ 5029
6282< 0.0197.40%
0.045 Random
51.7% (43.8%- 59.6%)
Gastrointestinal symptoms							
China
30
1308
< 0.0170.4%
0.014 Random
7.8% (5.1%-11.2%)
US
8
2470
< 0.0195.7%
0.025 Random
20.5% (12.2%-30.4%)
Europe14
1807< 0.0183.0%
0.01 Random
17.9% (13.4%-22.9%)
other countries	  81232< 0.0188.6%
0.017 Random
24.1% (16.1%- 33.3%)
N < 5032	  702< 0.0177.8%
0.04 Random
12.6% (7.8%-18.5%)
N ≥ 50286115< 0.0191.7%
0.013 Random
15.2% (12.0%- 18.6%)
Respiratory symptoms							
China
33
1349
< 0.0183.4%
0.032 Random
51.5% (44.3%-58.7%)
US
10
2535
< 0.0198.0%
0.066 Random
65.8% (49.6%-80.2%)
Europe15
1851< 0.0196.8%
0.066 Random
60.4% (46.9%-73.1%)
other countries	  81023< 0.0195.1%
0.059 Random
57.5% (39.8%-74.4%)
N < 5039	  867< 0.0182.1%
0.052 Random
56.9% (48.8%- 64.7%)
N ≥ 50275891< 0.0197.6%
0.050 Random
56.6% (47.9%-65.0%)
Asymptomatic							
China
28
1228
< 0.0184.7%
0.034 Random
21.7% (15.5%-28.6%)
US	  3	  507
0.08
60.6%
0.005 Random
10.1% (4.6%-17.5%)
Europe125533< 0.0194.6%
0.017 Random
19.9% (13.9%-26.8%)
other countries	  6	  396
< 0.0196.4%
0.116 Random
27.3% (6.9%-54.6%)
N < 5029	  575< 0.0173.6%
0.035 Random
17.7% (11.9%-24.4%)
N ≥ 50207664< 0.0196.5%
0.027 Random
24.8% (18.6%-31.5%)1150

Epidemiological features of coronavirus disease 2019 in children: a meta-analysis

Figure 3. Funnel plot of publication bias of fever factors.

Figure 2. Sensitivity analysis of fever factors.

children were in the mild category. Fever andcough were the most common clinical symptoms in adults. A meta-analysis of adults from43 studies involving 3,600 patients were included. Among these patients, fever (83.3%[95% CI, 78.4%-87.7%]), cough (60.3% [95%CI, 54.2%-66.3%]), and fatigue (38.0% [95% CI,
29.8%-46.5%]) were the most common clinicalsymptoms82. Compared with adults, this study
found that the incidence of fever among children
was 55.8% (50.3%-61.3%), the incidence of respiratory symptoms was 56.8% (50.9%-62.5%),
and the incidence of chest tightness was 6.1%
(3.9%-8.6%). In general, the clinical manifestations in children, especially the symptoms
of fatigue, were not typical, which may be due
to children’s inability to express symptoms inwords. As for the incidence of gastrointestinal
symptoms83, a study of 204 adults from Wuhan,
China, found that 103 patients (50.5%) reported
a digestive symptom, including lack of appetite
in 81 (78.6%) cases and diarrhoea in 35 (34%)
cases. However, the incidence of gastrointestinal
symptoms in children in this study was 14.4%,
which was much lower than that in adults. Han
et al84 reported that 19.4% of adults had diarrhea
as the first symptom, while Wang et al26 reported that among 31 children in six provinces inNorthern China, 4 (12.9%) had vomiting anddiarrhea as the first clinical manifestation. It is
worth noting that the proportion of children withfever in this study is only 54.1%, which is very
low. In China temperature detection checkpoints
are found in public places, such as airports andsubways. However, it appears that temperature
measurements are of only a little value in children.
Since the clinical symptoms in children wererelatively mild and atypical, the proportion of
asymptomatic patients may be higher in children
than in adults. The incidence of asymptomaticpatients in this study is 21.1% (16.9%-25.8%)85. A
meta-analysis of adult cases found a prevalence ofasymptomatic infection in 9.0% (95% CI, 5.5%1151

J.-G. Wang, Z.-J. Zhong, Y.-F. Mo, L.-C. Wang, R. Chen

14.6%) of patients. Nishiura et al86 investigated565 Japanese citizens evacuated from Wuhan at
the end of January and revealed that the incidenceof asymptomatic infections was 30.8%. Anotherexample is the “Diamond Princess” cruise ship,
which was isolated in Japanese waters in earlyFebruary due to SARS-CoV-2 infection where
it was found that the incidence of asymptomatic
infections was 51.7%87. However, a recent study
from New York88 reported that 29 (87.9%) of 33
pregnant women who tested positive for SARSCoV-2 on admission did not have symptoms of
COVID-19 at the time of treatment. From theabove data, we can conclude that the number ofasymptomatic patients was underestimated earlier since such patients are often not diagnosed
due to their asymptomatic presentation. Thesepatients are still contagious89, and not diagnosing
them may lead to great difficulties in preventing and controlling the pandemic. Asymptomatic
infected patients must be taken into account inplanning for epidemic prevention and control,
and there should be an increased emphasis on
obtaining epidemiological history. As stated inthis study, 85.2% of the COVID-19 children had
an epidemiological history.
Laboratory Examinations andImaging Examination
In a systematic evaluation of adults82, lymphatic cell reduction was found in 57.4% of patients, and a few studies showed that those withlymphopenia had a 3-fold higher risk of developing severe COVID-1990. This study found thatthe lymphocytes decreased in 12% of children,which could also explain the lower rate of severe
disease (3.33%) and lower mortality rate (0.28%)
in children, against the severe rate of 25.6% andmortality rate 3.6%, respectively, in adults82,91.
SARS-COV-2 may directly attack lymphocytes
or destroy lymphoid organs, which are importantcomponents of the collective immune response.
Because the symptoms of children are mild,
all inflammatory markers are rarely increased,
and the inflammatory markers which were mostcommonly increased were CRP (22.2%), PCT(17.5%), LDH (32.3%), and ESR (20.5%). Others,
such as ferritin, TNF-α, IFN-γ, ALT, CK-MB,and Cr were not usually found to be elevated.
In terms of imaging, a meta-analysis ofadults92 found that the chest imaging abnormality rate in patients with confirmed COVID-19
was 91.6%, and ground-glass opacities wereseen in 68.1% cases. Our study found that1152

the imaging abnormality rate was 66.5%, andground-glass opacities were seen in 36.9% ofchildren. One reason is the airway expressionof the SARS-COV-2 receptor (ACE2). Also, theexpression of transmembrane serine protease 2(TMPRSS2) is lower in children than in adults93.
Therefore, screening in children, and in asymptomatic patients, should not rely on blood biochemical and imaging tests but should consider
the gold standard of viral nucleic acid testing of
respiratory specimens.
Multisystem Inflammatory Syndrome inChildren (MIS-C)
Since April 2020, eight cases of children withsevere inflammatory shock due to COVID-19
were reported in London, UK94, and more attention was drawn to this phenomenon due to its
critical nature, disproving the previous notionthat children with COVID-19 always presented
with mild disease. The disease was clinicallysimilar to Kawasaki Disease, involving multiple
organ systems, often accompanied by increased
inflammatory markers, which can readily leadto a shock95. It has been reported that 68% of
MIS-C require admission to intensive care units
and these patients had a mortality rate of 1.7%96.
However, the incidence of such cases is low(6.2%).
Limitations
Our study has a few key limitations. First, wefound considerable heterogeneity between studies
and significant publication bias between several
subgroups. Subgroup analysis failed to identify
the source of heterogeneity, which would affectthe accuracy of meta-analysis. Second, the study
was analysed during the outbreak. Many areas
affected by COVID-19 have not yet released clinical data sets, which could skew the results of thisanalysis. While the literature included different
regions and hospitals to exclude data duplication,a possibility of data duplication cannot be eliminated completely.

Conclusions
This review provides a comprehensive description of the clinical characteristics of children with
COVID-19 and provides clinical evidence which
can be useful in the prevention and control of theepidemic. The overall symptoms of COVID-19
children were mild, and the prognosis was good.

Epidemiological features of coronavirus disease 2019 in children: a meta-analysis

The primary basis for diagnosing infections withhuman coronaviruses is Real-Time Polymerase
Chain Reaction (RT-PCR) performed on upper orlower respiratory tract secretions. When screening children for COVID-19, suspected patientsshould not be immediately excluded based on
normal peripheral white blood cells and lymphocyte counts or normal imaging findings.

Conflict of Interest

The Authors declare that they have no conflict of interests.

Acknowledgements

We would like to thank Editage [www.editage.cn] for English language editing.

Funding

This article was not funded by any external organisations.

Authors’ Contribution

Data curation: Ji-Gan Wang, Zhi-Juan Zhong; Formal analysis: Yu-Fang Mo; Investigation: Li-Chuan Wang; Methodology: Rui-Chen; Project administration: Ji-Gan Wang,
Rui-Chen; Software: Ji-Gan Wang. Supervision: Ji-gan
Wang; Writing – original draft: Zhi-Juan Zhong, Yu-Fang
Mo; Writing – review & editing: Ji-Gan Wang.

References
1) Cucinotta D, Vanelli M. WHO Declares COVID-19
a Pandemic. Acta Biomed 2020; 91: 157-160.
2) Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y,
Ren R, Leung KSM, Lau EHY, Wong JY, Xing X,
Xiang N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao
J, Liu M, Tu W, Chen C, Jin L, Yang R, Wang Q,
Zhou S, Wang R, Liu H, Luo Y, Liu Y, Shao G, Li
H, Tao Z, Yang Y, Deng Z, Liu B, Ma Z, Zhang
Y, Shi G, Lam TTY, Wu JT, Gao GF, Cowling BJ,
Yang B, Leung GM, Feng Z. Early transmission
dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med 2020;
382: 1199-1207.
3) Zhang YH, Lin DJ, Xiao MF, Wang JC, Wei Y, Lei
ZX, Zeng ZQ, Li L, Li HA, Xiang W. [2019-novel
coronavirus infection in a three-month-old baby].
Zhonghua Er Ke Za Zhi 2020; 58: E006.
4) Park JY, Han MS, Park KU, Kim JY, Choi EH. First
pediatric case of Coronavirus disease 2019 in Korea. J Korean Med Sci 2020; 35: e124.
5) Chen F, Liu ZS, Zhang FR, Xiong RH, Chen Y,
Cheng XF, Wang WY, Ren J. The first case of critical childhood covid-19 in China. Zhonghua Er Ke
Za Zhi 2020; 58: 179-182.

6) Special Expert Group for Control of the Epidemicof Novel Coronavirus Pneumonia of the Chinese
Preventive Medicine Association. [An update on
the epidemiological characteristics of novel coronavirus pneumonia (COVID-19)]. Zhonghua Liu
Xing Bing Xue Za Zhi 2020; 41: 139-144.
7) (Released by National Health Commission & National Administration of Traditional Chinese Medicine on March 3, 2020). Diagnosis and treatment
protocol for Novel Coronavirus pneumonia (Trial Version 7). Chin Med J (Engl) 2020; 133: 10871095.
8) Shen KL, Yang YH, Jiang RM, Wang TY, Zhao DC,
Jiang Y, Lu XX, Jin RM, Zheng YJ, Xu BP, Xie ZD,
Liu ZS, Li XW, Lin LK, Shang YX, Shu SN, Bai Y,
Lu M, Lu G, Deng JK, Luo WJ, Xiong LJ, Liu M,
Cui YX, Ye LP, Li JF, Shao JB, Gao LW, Wang YY,
Wang XF. Updated diagnosis, treatment and prevention of COVID-19 in children: experts’ consensus statement (condensed version of the second
edition). World J Pediatr 2020; 16: 232-239.
9) Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, Tong
S. Epidemiology of COVID-19 among children in
China. Pediatrics 2020; 145: e20200702.
10) Abraham C, Kelly MP, West R, Michie S. The
UK National Institute for Health and Clinical Excellence public health guidance on behaviourchange: a brief introduction. Psychol Health Med
2009; 14: 1-8.
11) Ma YL, Xia SY, Wang M, Zhang SM, Du WH,
Chen Q. Clinical characteristics of 115 cases ofnovel Coronavirus infected children. Zhongguo
Dang Dai Er Ke Za Zhi 2020; 22: 290-293.
12) Wu HP, Li JF, Chen X, Hu HZ, Jiang SA, Cheng
H, Hu XH, Tang JX, Zhong FC, Zeng LW, Yu W,
Yuan Y, Wu XF, Li YP, Zheng ZL, Pan TB, Wu ZX,
Yuan JF, Chen Q. Clinical analysis of 23 cases of
COVID-19 in children under 18 years of age in Jiangxi. Zhongguo Dang Dai Er Ke Za Zhi 2020; 22:419-424.
13) Wang KJ, Xu L, Yin H, Qiu JH, Feng QQ, Liu C,
Zhu GW, Wu DH. Clinical features and CT imaging of children with Covid-19. Hubei Yi Yao Xue
Yuan Xue Bao 2020; 39: 134-138.
14) Cao AH, Duan CH, Qiu BP, Lu L, Li KL, Liu XG,
Zhou ZY, Sun JiH, Ju XL. Epidemiology and clinical characteristics of children infected with coronavirus in Shandong province. Shandong Da Xue
Xue Bao 2020; 58: 34-40+70.
15) Zhou Y, Yang GD, Feng K, Huang H, Yun YX,
Mou XY, Wang LF. Clinical characteristics andchest CT manifestations of COVID-19 in infants
and young children. Zhongguo Dang Dai Er Ke
Za Zhi 2020; 2: 215-220.
16) Xiong JX, Zhou CY, Zeng WB. CT manifestationsof children’s novel coronavirus. Chongqing Yi Xue
2020; 49: 2837-2838.
17) Zhong Z, Xie X, Huang W, Zhao W, Yu Q, Liu J.
Chest CT findings and clinical features of coronavirus disease 2019 in children. Zhong Nan Da
Xue Xue Bao Yi Xue Ban 2020; 45: 236-242.

1153

J.-G. Wang, Z.-J. Zhong, Y.-F. Mo, L.-C. Wang, R. Chen18) Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D.
Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19)
in Zhejiang, China: an observational cohort study.
Lancet Infect Dis 2020; 20: 689-696.
19) Li B, Shen J, Li L, Yu C. Radiographic and clinical features of children with Coronavirus Disease(COVID-19) pneumonia. Indian Pediatr 2020; 57:
423-426.
20) Song W, Li J, Zou N, Guan W, Pan J, Xu W. Clinical features of pediatric patients with coronavirus disease (COVID-19). J Clin Virol 2020; 127:
104377.
21) Tan X, Huang J, Zhao F, Zhou Y, Li JQ, Wang XY.
Zhongguo Dang Dai Er Ke Za Zhi 2020; 22: 294298.
22) Götzinger F, Santiago-García B, Noguera-JuliánA, Lanaspa M, Lancella L, Calò Carducci FI,
Gabrovska N, Velizarova S, Prunk P, Osterman
V, Krivec U, Lo Vecchio A, Shingadia D, Soriano-Arandes A, Melendo S, Lanari M, Pierantoni L, Wagner N, L’Huillier AG, Heininger U, Ritz
N, Bandi S, Krajcar N, Roglić S, Santos M, Christiaens C, Creuven M, Buonsenso D, Welch SB,
Bogyi M, Brinkmann F, Tebruegge M. COVID-19
in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health 2020; 4: 653-661.
23) CDC COVID-19 Response Team. Coronavirus
Disease 2019 in children - United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly
Rep 2020; 69: 422-426.
24) Bai K, Liu W, Liu C, Fu Y, Hu J, Qin Y, Zhang
Q, Chen H, Xu F, Li C. Clinical analysis of 25
COVID-19 infections in children. Pediatr Infect Dis
J 2020; 39: e100-e103.
25) Wang D, Ju XL, Xie F, Lu Y, Li FY, Huang HH,
Fang XL, Li YJ, Wang JY, Yi B, Yue JX, Wang J,
Wang LX, Li B, Wang Y, Qiu BP, Zhou ZY, Li KL,
Sun JH, Liu XG, Li GD, Wang YJ, Cao AH, Chen
YN. [Clinical analysis of 31 cases of 2019 novel
coronavirus infection in children from six provinces (autonomous region) of northern China]. Zhonghua Er Ke Za Zhi 2020; 58: 269-274.
26) Soltani J, Sedighi I, Shalchi Z, Sami G, Moradveisi B, Nahidi S. Pediatric coronavirus disease 2019
(COVID-19): An insight from West of Iran. North
Clin Istanb 2020; 7: 284-291.
27) Lu Y, Wen H, Rong D, Zhou Z, Liu H. Clinicalcharacteristics and radiological features of children infected with the 2019 novel coronavirus.
Clin Radiol 2020; 75: 520-525.
28) Steinberger S, Lin B, Bernheim A, Chung M, Gao
Y, Xie Z, Zhao T, Xia J, Mei X, Little BP. CT features of Coronavirus Disease (COVID-19) in 30
pediatric patients. AJR Am J Roentgenol 2020;
215: 1303-1311.
29) Li Y, Cao J, Zhang X, Liu G, Wu X, Wu B. Chest
CT imaging characteristics of COVID-19 pneumonia in preschool children: a retrospective study.
BMC Pediatr 2020; 20: 227.

115430) Zhu L, Wang J, Huang R, Liu L, Zhao H, Wu C,
Zhu C. Clinical characteristics of a case series ofchildren with coronavirus disease 2019. Pediatr
Pulmonol 2020; 55: 1430-1432.
31) Dodi I, Castellone E, Pappalardo M, Rubini M,
Veronese P, Ruberto C, Bianchi L, Iovane B, Maffini V. SARS-CoV-2 infection in children in Parma.
Acta Biomed 2020; 91: 214-215.
32) Zheng G, Wang B, Zhang H, Xie C, Zhang Y, Wen
Z, Guo Q, Zhu H, Ye G, Liang J, Meng Q, Xie J,
Jiang S, Liu G, Gao W, Wang Y, Guo Y. Clinical characteristics of acute respiratory syndrome
with SARS-CoV-2 infection in children in South
China. Pediatr Pulmonol 2020; 55: 2419-2426.
33) Foster CE, Moulton EA, Munoz FM, Hulten KG,
Versalovic J, Dunn J, Revell P, Koy TH, Arrington
AS, Marquez L, Campbell J. Coronavirus Disease2019 in children cared for at Texas children’s hospital: initial clinical characteristics and outcomes.
J Pediatric Infect Dis Soc 2020; 9: 373-377.
34) Chen Z, Tong L, Zhou Y, Hua C, Wang W, Fu J,
Shu Q, Hong L, Xu H, Xu Z, Chen Y, Mao Y, Ye
S, Wu X, Wang L, Luo Y, Zou X, Tao X, Zhang
Y. Childhood COVID-19: a multicentre retrospective study. Clin Microbiol Infect 2020; 26: 1260.e11260.e4.
35) Du W, Yu J, Wang H, Zhang X, Zhang S, Li Q,
Zhang Z. Clinical characteristics of COVID-19 inchildren compared with adults in Shandong Province, China. Infection 2020; 48: 445-452.
36) Korkmaz MF, Türe E, Dorum BA, Kılıç ZB. The
Epidemiological and clinical characteristics of 81
children with COVID-19 in a pandemic hospital in
Turkey: an observational cohort study. J Korean
Med Sci 2020; 35: e236.
37) DeBiasi RL, Song X, Delaney M, Bell M, Smith
K, Pershad J, Ansusinha E, Hahn A, Hamdy R,
Harik N, Hanisch B, Jantausch B, Koay A, Steinhorn R, Newman K, Wessel D. Severe coronavirus disease-2019 in children and young adults inthe Washington, DC, Metropolitan Region. J Pediatr 2020; 223: 199-203.e1.
38) Zhang C, Gu J, Chen Q, Deng N, Li J, Huang L,
Zhou X. Clinical and epidemiological characteristics of pediatric SARS-CoV-2 infections in China:
a multicenter case series. PLoS Med 2020; 17:e1003130.
39) Gampel B, Troullioud Lucas AG, Broglie L, Gartrell-Corrado RD, Lee MT, Levine J, Orjuela-Grimm M, Satwani P, Glade-Bender J, Roberts
SS. COVID-19 disease in New York City pediatrichematology and oncology patients. Pediatr Blood
Cancer 2020; 67: e28420.
40) Zachariah P, Johnson CL, Halabi KC, Ahn D,
Sen AI, Fischer A, Banker SL, Giordano M, Manice CS, Diamond R, Sewell TB, Schweickert AJ,
Babineau JR, Carter RC, Fenster DB, Orange JS,
McCann TA, Kernie SG, Saiman L. Epidemiology,
clinical features, and disease severity in patientswith Coronavirus Disease 2019 (COVID-19) in achildren’s hospital in New York City, New York.
JAMA Pediatr 2020; 174: e202430.

Epidemiological features of coronavirus disease 2019 in children: a meta-analysis41) Armann JP, Diffloth N, Simon A, Doenhardt M,
Hufnagel M, Trotter A, Schneider D, Hübner J,
Berner R. Hospital admission in children and adolescents with COVID-19. Dtsch Arztebl Int 2020;
117: 373-374.
42) de Ceano-Vivas M, Martín-Espín I, Del Rosal T, Bueno-Barriocanal M, Plata-Gallardo
M, Ruiz-Domínguez JA, López-López R, Molina-Gutiérrez M, Bote-Gascón P, González-Bertolín I, García-Sánchez P, Martín-Sánchez J, deMiguel-Lavisier B, Sainz T, Baquero-Artigao F,
Méndez-Echevarría A, Calvo C. SARS-CoV-2 infection in ambulatory and hospitalised Spanish
children. Arch Dis Child 2020; 105: 808-809.
43) Gao Y, Zhang D, Sui S, Xu R. Clinical features
and treatment protocol in eleven Chinese children with mild COVID-19. Indian J Pediatr 2020;
87: 748.
44) Mannheim J, Gretsch S, Layden JE, Fricchione MJ. Characteristics of hospitalized pediatricCoronavirus Disease 2019 cases in Chicago, Illinois, March-April 2020. J Pediatric Infect Dis Soc
2020; 9: 519-522.
45) Chao JY, Derespina KR, Herold BC, Goldman
DL, Aldrich M, Weingarten J, Ushay HM, Cabana
MD, Medar SS. Clinical characteristics and outcomes of hospitalized and critically ill children
and adolescents with Coronavirus Disease 2019at a tertiary care medical center in New York City.
J Pediatr 2020; 223: 14-19.e2.
46) Fakiri KE, Nassih H, Sab IA, Draiss G, Bouskraoui M. Epidemiology and clinical features ofCoronavirus disease 2019 in Moroccan children.
Indian Pediatr 2020, 57: 808-810.
47) Li W, Fang Y, Liao J, Yu W, Yao L, Cui H, Zeng
X, Li S, Huang C. Clinical and CT features of the
COVID-19 infection: comparison among four different age groups. Eur Geriatr Med 2020; 11: 843-850.
48) Parri N, Magistà AM, Marchetti F, Cantoni B, Arrighini A, Romanengo M, Felici E, Urbino A, Da
Dalt L, Verdoni L, Armocida B, Covi B, Mariani I,
Giacchero R, Musolino AM, Binotti M, Biban P,
Fasoli S, Pilotto C, Nicoloso F, Raggi M, Miorin E,
Buonsenso D, Chiossi M, Agostiniani R, Plebani
A, Barbieri MA, Lanari M, Arrigo S, Zoia E, Lenge
M, Masi S, Barbi E, Lazzerini M. Characteristicof COVID-19 infection in pediatric patients: earlyfindings from two Italian Pediatric Research Networks. Eur J Pediatr 2020; 179: 1315-1323.
49) Victor G. COVID-19 admissions calculators: general population and paediatric cohort. Early Hum
Dev 2020; 145: 105043.
50) Otto WR, Geoghegan S, Posch LC, Bell LM, Coffin SE, Sammons JS, Harris RM, Odom John AR,
Luan X, Gerber JS. The epidemiology of Severe
Acute Respiratory Syndrome Coronavirus 2 in apediatric healthcare network in the United States.
J Pediatric Infect Dis Soc 2020; 9: 523-529.
51) Zhang L, Huang S. clinical features of 33 cases inchildren infected with SARS-CoV-2 in Anhui province, china-a multi-center retrospective cohort
study. Front Public Health 2020; 8: 255.

52) Brisca G, Ferretti M, Sartoris G, Damasio MB,
Buffoni I, Pirlo D, Romanengo M, Piccotti E. The
early experiences of a single tertiary Italian emergency department treating COVID-19 in children.
Acta Paediatr 2020 Jun 30:10.1111/apa.15451.
doi: 10.1111/apa.15451. Epub ahead of print.
53) Gaborieau L, Delestrain C, Bensaid P, Vizeneux
A, Blanc P, Garraffo A, Georget E, Chalvon A,
Garrec N, Laoudi Y, Varon E, Rouget S, Pupin A,
Abdel Aal K, Toulorge D, Ducrocq S, Barrey C,
Pantalone L, Robert B, Joly-Sanchez L, Thach C,
Masserot-Lureau C, Chahine J, Garcia-Roudaut
VR, Rozental J, Nathanson S, Khaled M, Mandelcwajg A, Demayer N, Muller S, Mazerghane
M, Epaud R, Pellegrino B, Madhi F. Epidemiology
and clinical presentation of children hospitalizedwith SARS-CoV-2 infection in suburbs of Paris. J
Clin Med 2020; 9: 2227.
54) Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and CT features in pediatric patients with
COVID-19 infection: Different points from adults.
Pediatr Pulmonol 2020; 55: 1169-1174.
55) Du H, Dong X, Zhang JJ, Cao YY, Akdis M,
Huang PQ, Chen HW, Li Y, Liu GH, Akdis CA, Lu
XX, Gao YD. Clinical characteristics of 182 pediatric COVID-19 patients with different severities
and allergic status. Allergy 2020 Jun 10:10.1111/
all.14452. doi: 10.1111/all.14452. Epub ahead ofprint.
56) Tan YP, Tan BY, Pan J, Wu J, Zeng SZ, Wei HY.
Epidemiologic and clinical characteristics of 10
children with coronavirus disease 2019 in Changsha, China. J Clin Virol 2020; 127: 104353.
57) Ma H, Hu J, Tian J, Zhou X, Li H, Laws MT, Wesemann LD, Zhu B, Chen W, Ramos R, Xia J,
Shao J. A single-center, retrospective study of
COVID-19 features in children: a descriptive investigation. BMC Med 2020; 18: 123.
58) Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, Zhang
W, Wang Y, Bao S, Li Y, Wu C, Liu H, Liu D, Shao
J, Peng X, Yang Y, Liu Z, Xiang Y, Zhang F, Silva
RM, Pinkerton KE, Shen K, Xiao H, Xu S, Wong
GWK. SARS-CoV-2 Infection in Children. N Engl
J Med 2020; 382: 1663-1665.
59) Zheng F, Liao C, Fan QH, Chen HB, Zhao XG, Xie
ZG, Li XL, Chen CX, Lu XX, Liu ZS, Lu W, Chen
CB, Jiao R, Zhang AM, Wang JT, Ding XW, Zeng
YG, Cheng LP, Huang QF, Wu J, Luo XC, Wang
ZJ, Zhong YY, Bai Y, Wu XY, Jin RM. Clinicalcharacteristics of children with Coronavirus Disease 2019 in Hubei, China. Curr Med Sci 2020;
40: 275-280.
60) Sun D, Chen X, Li H, Lu XX, Xiao H, Zhang FR,
Liu ZS. SARS-CoV-2 infection in infants under 1
year of age in Wuhan City, China. World J Pediatr
2020; 16: 260-266.
61) Xiong X, Chua GT, Chi S, Kwan MYW, Sang
Wong WH, Zhou A, Shek CC, Tung KTS, Qin H,
Wong RS, Li X, Chen P, Li S, Chui CS, Tso WWY,
Ho MHK, Wong ICK, Chan GCF, Lau YL, Wong
KKY, Chung PHY, Li H, Tam PKH, Tang ST, Ip P.
A Comparison between Chinese children infect-1155

J.-G. Wang, Z.-J. Zhong, Y.-F. Mo, L.-C. Wang, R. Chen

62)

63)

64)

65)

66)

67)

68)

69)

70)

ed with coronavirus disease-2019 and with severe acute respiratory syndrome 2003. J Pediatr
2020; 224: 30-36.
Song X, Delaney M, Shah RK, Campos JM, Wessel DL, DeBiasi RL. Comparison of clinical features of COVID-19 vs seasonal influenza A and
B in US children. JAMA Netw Open 2020; 3:e2020495.
Posfay-Barbe KM, Wagner N, Gauthey M, Moussaoui D, Loevy N, Diana A, L’Huillier AG. COVID-19
in children and the dynamics of infection in families. Pediatrics 2020; 146: e20201576.
Jiehao C, Jin X, Daojiong L, Zhi Y, Lei X, Zhenghai Q, Yuehua Z, Hua Z, Ran J, Pengcheng L,
Xiangshi W, Yanling G, Aimei X, He T, Hailing C,
Chuning W, Jingjing L, Jianshe W, Mei Z. A caseseries of children with 2019 Novel Coronavirus infection: clinical and epidemiological features. Clin
Infect Dis 2020; 71: 1547-1551.
Kim L, Whitaker M, O’Halloran A, Kambhampati A, Chai SJ, Reingold A, Armistead I, Kawasaki B, Meek J, Yousey-Hindes K, Anderson EJ,
Openo KP, Weigel A, Ryan P, Monroe ML, Fox K,
Kim S, Lynfield R, Bye E, Shrum Davis S, Smelser C, Barney G, Spina NL, Bennett NM, Felsen
CB, Billing LM, Shiltz J, Sutton M, West N, Talbot HK, Schaffner W, Risk I, Price A, Brammer L,
Fry AM, Hall AJ, Langley GE, Garg S. Hospitalization rates and characteristics of children aged
<18 years hospitalized with laboratory-confirmed
COVID-19 - COVID-NET, 14 states, March 1-July 25, 2020. MMWR Morb Mortal Wkly Rep 2020;
69: 1081-1088.
Loconsole D, Caselli D, Centrone F, Morcavallo
C, Campanella S, Aricò M, Chironna M. SARSCoV-2 Infection in children in Southern Italy: adescriptive case series. Int J Environ Res Public
Health 2020; 17: 6080.
Swann OV, Holden KA, Turtle L, Pollock L, Fairfield CJ, Drake TM, Seth S, Egan C, Hardwick
HE, Halpin S, Girvan M, Donohue C, Pritchard
M, Patel LB, Ladhani S, Sigfrid L, Sinha IP, Olliaro PL, Nguyen-Van-Tam JS, Horby PW, Merson
L, Carson G, Dunning J, Openshaw PJM, Baillie
JK, Harrison EM, Docherty AB, Semple MG. Clinical characteristics of children and young people
admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ 2020; 370: m3249.
Norooznezhad AH, Najafi F, Riahi P, Moradinazar M, Shakiba E, Mostafaei S. Primary symptoms, comorbidities, and outcomes of 431 hospitalized patients with confirmative RT-PCR resultsfor COVID-19. Am J Trop Med Hyg 2020; 103:834-837.
Giacomet V, Barcellini L, Stracuzzi M, Longoni E,
Folgori L, Leone A, Zuccotti GV. Gastrointestinal
symptoms in severe COVID-19 children. Pediatr
Infect Dis J 2020; 39: e317-e320.
Moreno-Galarraga L, Urretavizcaya-Martínez M,
Alegría Echauri J, García Howard M, Ruperez
García E, Aguilera-Albesa S, Alzina de Aguilar V,

1156

71)

72)

73)

74)

75)

76)

77)

78)

79)

Herranz Aguirre M. SARS-CoV-2 infection in children requiring hospitalization: the experience ofNavarra, Spain. World J Pediatr 2020; 16: 614622.
Ranabothu S, Onteddu S, Nalleballe K, Dandu V,
Veerapaneni K, Veerapandiyan A. Spectrum of
COVID-19 in children. Acta Paediatr 2020; 109:
1899-1900.
Mamishi S, Heydari H, Aziz-Ahari A, Shokrollahi
MR, Pourakbari B, Mahmoudi S, Movahedi Z. Novel coronavirus disease 2019 (COVID-19) outbreakin children in Iran: atypical CT manifestations
and mortality risk of severe COVID-19 infection.
J Microbiol Immunol Infect 2020 Aug 6:S16841182(20)30177-8. doi: 10.1016/j.jmii.2020.07.019.
Epub ahead of print.
Maltezou HC, Magaziotou I, Dedoukou X, Eleftheriou E, Raftopoulos V, Michos A, Lourida A,
Panopoulou M, Stamoulis K, Papaevangelou V,
Petinaki E, Mentis A, Papa A, Tsakris A, Roilides
E, Syrogiannopoulos GA, Tsolia M. Children andadolescents with SARS-CoV-2 infection: epidemiology, clinical course and viral loads. Pediatr Infect Dis J 2020; 39: e388-e392.
Han MS, Choi EH, Chang SH, Jin BL, Lee EJ,
Kim BN, Kim MK, Doo K, Seo JH, Kim YJ, Kim
YJ, Park JY, Suh SB, Lee H, Cho EY, Kim DH,
Kim JM, Kim HY, Park SE, Lee JK, Jo DS, Cho
SM, Choi JH, Jo KJ, Choe YJ, Kim KH, Kim JH.
Clinical characteristics and viral RNA detection
in children with Coronavirus Disease 2019 in the
Republic of Korea. JAMA Pediatr 2020: e203988.
doi: 10.1001/jamapediatrics.2020.3988. Epubahead of print.
Mohammadi A, Mohebbi I, Khademvatani K,
Pirnejad H, Mirza-Aghazadeh J, Gharebaghi N,
Abbasian Ardakani A, Mirza-Aghazadeh-Attari M.
Clinical and radiological characteristics of pediatric patients with COVID-19: focus on imaging findings. Jpn J Radiol 2020; 38: 987-992.
Storch-de-Gracia P, Leoz-Gordillo I, Andina
D, Flores P, Villalobos E, Escalada-Pellitero S,
Jiménez R. [Clinical spectrum and risk factors forcomplicated disease course in children admittedwith SARS-CoV-2 infection]. An Pediatr (Barc)
2020; 93: 323-333.
Oterino Serrano C, Alonso E, Andrés M, Buitrago NM, Pérez Vigara A, Parrón Pajares M, Cuesta López E, Garzón Moll G, Martin Espin I, Bueno Barriocanal M, De Ceano-Vivas la Calle M,
Calvo Rey C, Bret-Zurita M. Pediatric chest x-ray
in covid-19 infection. Eur J Radiol 2020; 131:
109236.
Bellino S, Punzo O, Rota MC, Del Manso M, Urdiales AM, Andrianou X, Fabiani M, Boros S,
Vescio F, Riccardo F, Bella A, Filia A, Rezza G,
Villani A, Pezzotti P. COVID-19 disease severity
risk factors for pediatric patients in Italy. Pediatrics 2020; 146: e2020009399.
Yılmaz K, Gozupirinççioğlu A, Aktar F, Akın A,
Karabel M, Yolbas I, Uzel VH, Şen V. Evaluationof the novel coronavirus disease in Turkish chil-Epidemiological features of coronavirus disease 2019 in children: a meta-analysis

80)

81)

82)

83)

84)

85)

86)

dren: Preliminary outcomes. Pediatr Pulmonol
2020; 55: 3587-3594.
Cura Yayla BC, Özsürekçi Y, Aykaç K, Derin Oygar P, Laçinel Gürlevik S, İlbay S, Kukul MG, Karahan S, Cengiz AB, Ceyhan M. Characteristics
and management of children with COVID-19 in
Turkey. Balkan Med J 2020; 37: 341-347.
Elimian KO, Ochu CL, Ilori E, Oladejo J, Igumbor
E, Steinhardt L, Wagai J, Arinze C, Ukponu W,
Obiekea C, Aderinola O, Crawford E, Olayinka A,
Dan-Nwafor C, Okwor T, Disu Y, Yinka-Ogunleye
A, Kanu NE, Olawepo OA, Aruna O, Michael CA,
Dunkwu L, Ipadeola O, Naidoo D, Umeokonkwo
CD, Matthias A, Okunromade O, Badaru S, Jinadu A, Ogunbode O, Egwuenu A, Jafiya A, Dalhat
M, Saleh F, Ebhodaghe GB, Ahumibe A, Yashe
RU, Atteh R, Nwachukwu WE, Ezeokafor C, Olaleye D, Habib Z, Abdus-Salam I, Pembi E, John
D, Okhuarobo UJ, Assad H, Gandi Y, Muhammad
B, Nwagwogu C, Nwadiuto I, Sulaiman K, Iwuji I,
Okeji A, Thliza S, Fagbemi S, Usman R, Mohammed AA, Adeola-Musa O, Ishaka M, Aketemo U,
Kamaldeen K, Obagha CE, Akinyode AO, Nguku
P, Mba N, Ihekweazu C. Descriptive epidemiology of coronavirus disease 2019 in Nigeria, 27
February-6 June 2020. Epidemiol Infect 2020;
148: e208.
Fu L, Wang B, Yuan T, Chen X, Ao Y, Fitzpatrick
T, Li P, Zhou Y, Lin YF, Duan Q, Luo G, Fan S, Lu
Y, Feng A, Zhan Y, Liang B, Cai W, Zhang L, Du
X, Li L, Shu Y, Zou H. Clinical characteristics ofcoronavirus disease 2019 (COVID-19) in China:
a systematic review and meta-analysis. J Infect2020; 80: 656-665.
Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J, Li
P, Hu B, Wang J, Hu C, Jin Y, Niu X, Ping R, Du
Y, Li T, Xu G, Hu Q, Tu L. Clinical characteristics
of COVID-19 patients with digestive symptoms
in Hubei, China: a descriptive, cross-sectional,
multicenter study. Am J Gastroenterol 2020; 115:766-773.
Han C, Duan C, Zhang S, Spiegel B, Shi H, Wang
W, Zhang L, Lin R, Liu J, Ding Z, Hou X. Digestive symptoms in COVID-19 patients with mild
disease severity: clinical presentation, stool viral
RNA testing, and outcomes. Am J Gastroenterol
2020; 115: 916-923.
He J, Guo Y, Mao R, Zhang J. Proportion of asymptomatic coronavirus disease 2019: A systematic review and meta-analysis. J Med Virol2020 Jul 21: 10.1002/jmv.26326. doi: 10.1002/
jmv.26326. Epub ahead of print.
Nishiura H, Kobayashi T, Miyama T, Suzuki A,
Jung SM, Hayashi K, Kinoshita R, Yang Y, Yuan
B, Akhmetzhanov AR, Linton NM. Estimation of
the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis 2020; 94: 154155.

87) Mizumoto K, Kagaya K, Zarebski A, Chowell G.
Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board
the Diamond Princess cruise ship, Yokohama,Japan, 2020. Euro Surveill 2020; 25: 2000180.
88) Sutton D, Fuchs K, D’Alton M, Goffman D. Universal Screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med 2020; 382: 21632164.
89) Gao M, Yang L, Chen X, Deng Y, Yang S, Xu H,
Chen Z, Gao X. A study on infectivity of asymptomatic SARS-CoV-2 carriers. Respir Med 2020;
169: 106026.
90) Zhao Q, Meng M, Kumar R, Wu Y, Huang J,
Deng Y, Weng Z, Yang L. Lymphopenia is associated with severe coronavirus disease 2019
(COVID-19) infections: a systemic review and meta-analysis. Int J Infect Dis 2020; 96: 131-135.
91) Fathi N, Rezaei N. Lymphopenia in COVID-19:
Therapeutic opportunities. Cell Biol Int 2020; 44:
1792-1797.
92) Zhu J, Zhong Z, Li H, Ji P, Pang J, Li B, Zhang
J. CT imaging features of 4121 patients with
COVID-19: A meta-analysis. J Med Virol 2020; 92:
891-902.
93) Saheb Sharif-Askari N, Saheb Sharif-Askari F, Alabed M, Temsah MH, Al Heialy S, Hamid Q, Halwani R. Airways expression of SARS-CoV-2 receptor, ACE2, and TMPRSS2 is lower in children than adults and increases with smoking and
COPD. Mol Ther Methods Clin Dev 2020; 18: 1-6.
94) Dolhnikoff M, Ferreira Ferranti J, de Almeida Monteiro RA, Duarte-Neto AN, Soares Gomes-Gouvêa M, Viu Degaspare N, Figueiredo Delgado A,
Montanari Fiorita C, Nunes Leal G, Rodrigues
RM, Taverna Chaim K, Rebello Pinho JR, Carneiro-Sampaio M, Mauad T, Ferraz da Silva LF,
Brunow de Carvalho W, Saldiva PHN, Garcia Caldini E. SARS-CoV-2 in cardiac tissue of a childwith COVID-19-related multisystem inflammatory
syndrome. Lancet Child Adolesc Health 2020; 4:
790-794.
95) Henderson LA, Canna SW, Friedman KG, Gorelik
M, Lapidus SK, Bassiri H, Behrens EM, Ferris A,
Kernan KF, Schulert GS, Seo P, F Son MB, Tremoulet AH, Yeung RSM, Mudano AS, Turner AS,
Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for multisystem inflammatory syndrome in children associated with
SARS-CoV-2 and hyperinflammation in pediatric
COVID-19: Version 1. Arthritis Rheumatol 2020
Jul 23: 10.1002/art.41454. doi: 10.1002/art.41454.
Epub ahead of print.
96) Kanthimathinathan HK, Scholefield BR. Pediatricinflammatory multisystem syndrome: time to collaborate. J Pediatric Infect Dis Soc 2020: piaa105.
doi: 10.1093/jpids/piaa105. Epub ahead of print.

1157