The prevalence of coronavirus disease 2019 (COVID‐19) is lower in children compared with adults. Children contribute to 1%‐5% of all COVID‐19 cases. 1 A recent study from China reported that 171 (12.3%) of 1391 children with suspected disease had confirmed COVID‐19 infection. 2 As of May 15, 2020, there are 33,241 children with COVID‐19 in the United States. 3 The most common symptoms in children with confirmed and suspected COVID‐19 include fever and cough followed by diarrhoea and abdominal pain. A very few children developed critical illness coagulopathy, respiratory failure, shock and renal injury. 4 Severe manifestations of COVID‐19 are reported in children younger than 1 year of age and children with comorbid conditions. 4 The majority of children with COVID‐19 in the United States that required hospitalisation had one or more underlying medical conditions such as chronic lung disease, cardiovascular disease and immunosuppression. 5 Despite the available limited information, COVID‐19 in children poses a significant challenge due to the atypical/asymptomatic presentations and role in community transmission. Knowledge regarding the clinical characteristics and disease burden in children is critical at this stage of the pandemic for better treatment, control of transmission and appropriate allocation of healthcare resources. Data regarding organ system‐specific involvement of COVID‐19 are lacking.
We used TriNetX, a global health collaborative clinical research platform that collects real‐time electronic medical record data from various healthcare organisations. Our search criteria included children from 0 to 18 years of age with a confirmed laboratory diagnosis of COVID‐19 from January 20, 2020, to June 10, 2020. We used laboratory codes to identify children with confirmed COVID‐19 and to gather information on symptoms and organ system involvement. We used a time constraint of 1 month in the search criteria for any new diagnoses reported on or after the diagnosis of COVID‐19. We analysed the data based on age, demographic distribution, symptoms and organ system involvement. There were a total of 1353 children in the database that met the aforementioned criteria. Demographics and clinical characteristics of these patients are described in Table 1. The most common symptoms include fever and cough. Interestingly, loss of smell/taste sensation was reported only in a minority of children and they were 11 years or older. This might be related to the inability of younger children to express this peculiar symptom. About organ system involvement, the majority of the children had respiratory system involvement with acute upper respiratory infection being the most common diagnosis. Cardiac involvement was reported in 6.4% of the children with acute myocardial infarction and myocarditis in ≤10 children each. Kawasaki disease was reported in only 16 of the 1353 children. We were unable to obtain data on the multisystem inflammatory syndrome in children (MIS‐C) reported with COVID‐19 as there is no International Classification of Diseases (ICD)‐10 diagnosis code for it.
Table 1.
Presentations of children in COVID‐19
| Characteristics | N = 1353 (100%) |
|---|---|
| Age distribution‐ no. (%) | |
| <1 y | 155 (11.4%) |
| 1‐5 y | 284 (21%) |
| 6‐10 y | 205 (15.2%) |
| 11‐18 y | 709 (52.4%) |
| Sex ‐ no. (%) | |
| Female | 659 (49%) |
| Male | 694 (51%) |
| Race‐ no. (%) | |
| White | 455 (34%) |
| Black or African American | 223 (16%) |
| Asian | 29 (2%) |
| Unknown Race | 646 (48%) |
| Ethnicity‐ no. (%) | |
| Not Hispanic or Latino | 297 (22%) |
| Unknown | 789 (58%) |
| Hispanic or Latino | 267 (20%) |
| Hospital admission‐ no. (%) | |
| Inpatient/Observation | 260 (19.2%) |
| Intensive Care Unit (ICU) | 26 (1.9%) |
| Symptoms ‐ no. (%) | |
| Fever | 293 (21.7%) |
| Cough | 209 (15.4%) |
| Abnormal breathing | 109 (8.1%) |
| Sore throat | 58 (4.3%) |
| Abdominal/pelvic pain | 56 (4.1%) |
| Headache | 54 (4.0%) |
| Nausea/Vomiting | 45 (3.3%) |
| Diarrhea | 42 (3.1%) |
| Concerning food/fluid intake | 36 (2.7%) |
| Rash and other skin eruptions | 36 (2.7%) |
| Malaise/Fatigue | 33 (2.4%) |
| Loss of smell/taste | 28 (2.1%) |
| Myalgias | 22 (1.6%) |
| Emotional disturbances | 19 (1.4%) |
| Nasal congestion | 15 (1.1%) |
| Convulsions | ≤10 (≤0.7%) |
| Dizziness | ≤10 (≤0.7%) |
| Non‐specific symptoms of Infancy | ≤10 (≤6.5% of Infants) |
| Organ system involvement‐ no. (%) | |
| Respiratory system | 400 (29.6%) |
| Acute upper respiratory infection | 150 (11.1%) |
| Intubation | ≤10 (≤0.7%) |
| Endocrine/Nutritional/Metabolic | 116 (8.6%) |
| Disorders of blood & immune system | 103 (7.6%) |
| Circulatory system | 87 (6.4%) |
| Acute MI | ≤10 (≤0.7%) |
| Myocarditis | ≤10 (≤0.7%) |
| Digestive system | 83 (6.1%) |
| Musculo‐skeletal/Connective Tissue | 82 (6.1%) |
| Kawasaki Disease | 16 (1.2%) |
| Toxic shock syndrome | 0 (0%) |
| Mental/Behavioral disorders | 65 (4.8%) |
| Anxiety disorders | 19 (1.4%) |
| Mood disorders | 22 (1.6%) |
| Nervous system | 62 (4.6%) |
| Sleep disorders | 16 (1.2%) |
| Stroke | ≤10 (≤0.7%) |
| GBS | 0 (0%) |
| Skin and subcutaneous tissue | 49 (3.6%) |
| Vasculitis limited to skin | 0 (0%) |
| Genito‐urinary system | 47 (3.5%) |
| Acute kidney Injury | 12 (0.9%) |
| Dialysis | ≤10 (≤0.7%) |
| Mortality | ≤10 (≤0.7%) |
We describe the clinical characteristics of children with confirmed COVID‐19 based on the data available in the largest database to date. The available information confirms multiple organ system involvement in children with COVID‐19 and only minority of children require hospitalisation and/or critical care. As this report is based on ICD‐10 codes entered from the electronic medical record, one should be cautious about establishing causation. Individual patient‐level data including outcomes could not be ascertained due to the nature of this study. Further systematic studies are needed to better understand the organ system‐specific manifestations of COVID‐19 in children, management and clinical outcomes.
CONFLICT OF INTEREST
All authors have no conflicts of interest to disclose.
ACKNOWLEDGEMENTS
Thank you to Naveen Nallaballe for his help with analysis. Data for the study were provided by the Arkansas Clinical Data Repository (AR‐CDR) maintained by the Department of Biomedical Informatics in the College of Medicine at the University of Arkansas for Medical Sciences (UAMS). The AR‐CDR is approved to operate as an enterprise data resource to support research across UAMS. Data in the AR‐CDR come from UAMS Electronic Medical Record (EMR), tumour registry, billing and cancer genomic data and comprise encounters since 05/01/2014.
REFERENCES
- 1. Jones VG, Mills M, Suarez D, et al. COVID‐19 and Kawasaki disease: novel virus and novel case. Hosp Pediatr. 2020;10(6):537‐540. [DOI] [PubMed] [Google Scholar]
- 2. Lu X, Zhang L, Du H, et al. SARS‐CoV‐2 infection in children. N Engl J Med. 2020;382(17):1663‐1665. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Coronavirus Disease 2019 (COVID‐19). https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html [Internet]. Accessed May 21, 2020.
- 4. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID‐19 among children in China. Pediatrics. 2020;145(6):e20200702. 10.1542/peds.2020-0702 [DOI] [PubMed] [Google Scholar]
- 5. CDC Covid‐19 Response Team . Coronavirus Disease 2019 in Children—United States, February 12‐April 2, 2020. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm. Accessed April 6, 2020.