May 2020 COVID-19 Pediatric Update

By Scott Field, MD, FCP, on May 1, 2020

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We hope that you are doing well in these trying times. The following information is provided to give you the latest update about the science behind this novel viral pandemic, along with references for those more academically inclined. The information from our original 3/16/20 and 4/01/20 handouts are still mostly accurate and pertinent. Stay tuned as new updates keep coming. Unlike much information that is circling mainstream media, all references in this update have been vetted by the ACPeds Scientific Policy Committee. 

Transmission

We are still learning about SARS-CoV-2 transmission, but the evidence points predominantly to droplet spread both before a person gets symptoms and during the time of symptoms, with most transmission from coughing.1-2 Droplet spread without coughing  can occur with sneezing, talking loudly, and to a small extent, with just breathing.3-4 We know that getting infected from contaminated surfaces probably occurs,2 but the extent of this form of SARS-CoV-2 transmission has yet to be determined. Infected people who never develop symptoms can also be contagious, but how much transmission occurs this way is also questionable.5 Likewise, people may get infected by aerosols (that unlike most droplets, hang in the air),2,6 but that is still not nearly as likely as from larger droplets.7-8

The main test to detect the SARS-CoV-2 virus, which causes COVID-19, is a sensitive polymerase chain reaction(PCR) test, but false negative tests may occur relatively frequently.9 Hence, someone who tests negative, but the test took more than a few days to process, may still have the disease. In the research setting, PCR measurements of the virus’ genetic material, ribonucleic acid (RNA), have found the greatest amounts in the first week of symptoms,10-11and more in coughed up sputum (phlegm) than in throat or nose swabs.12 Viral culture, which better represents actual infectivity, has been limited, but has been positive in saliva.4,10 Viral RNA by PCR has been frequently found in stool, sometimes weeks after symptoms,13-14 but limited attempts to grow the virus from stool samples have failed.10 It remains to be determined if the RNA presence in stool means that the virus can be readily transmitted like a stomach bug, but it is prudent to continue good surface and hand sanitizing.

Masks have been found to be helpful in reducing spread, mostly from an infected individual.15-16 Face shields have great potential for limiting droplet spread, but have not been sufficiently studied. As social distancing relaxation and return to more normal routines occurs, it will be very helpful for everyone to wear a facial barrier in public although this may be more difficult to achieve with very young children.

Pediatric COVID-19

Babies whose moms have COVID-19 at the time of birth generally do well, although some have had symptoms of fever or cough.16 The relatively few babies who do get infected generally recover quickly and don’t shed the virus very long. Breast milk generally has not been found to contain the virus.17-18

Children are relatively protected from severe disease, but infants under 1 year of age are at higher risk than older children.19-20 Children with underlying conditions such as asthma, cardiovascular disease, and immunosuppression have been more likely to be hospitalized.20 US data reveals less fever (56% vs. 71%) and cough (54% vs. 80%) in COVID 19 positive children under 18 years of age compared to COVID 19 positive adults aged 18-64-years-old.20 

References

  1. Guan L, Zhow L, Zhang J, Peng W, Chen R. More awareness is needed for severe acute respiratory syndrome coronavirus 2019 transmission through exhaled air during non-invasive respiratory support: experience in China. EurRespir J, 2020;55:2000352 https://doi.org/10.1183/13993003.00352-2020

  2. vanDoremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. NEJM.  Letter online Mar 17,2020 Doi: 10.1056/NEJMc2004973 

  3. Herfst S, Bohringer M, Karo B, et al. Drivers of airborne human-to-human pathogen transmission. Cur OpinVirol. 2017;22:22-29. http://dx.doi.org/10.1016/j.coviro.2016.11.006

  4. To KK-W, Tsang OT-Y, Yip CC-Y, et al. Consistent detection of 2019 novel coronavirus in saliva. CID. On line Feb 12,2020. Doi: 10.1093/cid/ciaa149 

  5. Hu Z, Song C, Xu C, etal.Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. On line Mar 4, 2020 Doi:  10.1007/s11427-020-1661-4 https://doi.org/10.1101/2020.02.20.20025619

  6. Guo Z-D, Wang Z-Y, Zhang S-F, et al. Aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards, Wuhan, China, 2020.MMWR Morb Mortal Wkly Rep.  2020;26(7) On line early release version

  7. Ong SWX, Tan YK, Chia PY, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA. On line Mar 4, 2020 

  8. Faridi S, Niaza S, Sadeghi, et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci Total Env. 2020;725:1-5 Https://doi.org/10.1016/j.scitotenv.2020.138401

  9. Li Y, Yao L, Li J, et al. Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19. J Med Virol. On line Mar 26, 2020 https://doi.org/10.1002/jmv.25786

  10. Wolfel R, Corman VM, Guggemos W, et al. Virological assessment of hospitalized patients with COVID-2019. Nature. Online Apr 1, 2020. https://doi.org/10.1038/s41586-020-2196-x

  11. To KK-W, Tsang OT-Y, Leung WS, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet. Online Mar 23, 2020. https://doi.org/10.1016/S1473-3099(20)30196-1

  12. Yu F, Yan L, Wang N, et al. Quantitative detection and viral load analysis of SARS-CoV-2 in infected patients. Oxford University Press of the Infectious Diseases Society of America. Online Apr 13, 2020 https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciaa345/5812997

  13. Xu Y, Li X, Zhu B, et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nat Med. 2020 https://doi.org/10.1038/s41591-020-0817-4

  14. Xing Y, Ni W, Wo Q, et al. Prolonged presence of SARS-CoV-2 in feces of pediatric patients during the convalescent phase. MedRxiv preprint https://doi.org/10.1101/2020.03.11.20033159

  15. Liu X, Zhang S. COVID-19: Face masks and human-to-human transmission. Influenza Other Viruses. Mar 16, 2020. Doi: 10.1111/irv.12740

  16. Leung NH, Chu DKW, Shiu EYC, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks.Nat Med. 2020 https://doi.org/10.1038/s41591-020-0843-2

  17. Zeng L, Xia S, Yuan W, et al. Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China. Letter JAMA Pediatrics. Mar 26,2020 on line;E1-E3.

  18. Cui Y, Tian M, Huang D, et al. A 55-day-old female infant infected with 2019 novel coronavirus disease: presenting with pneumonia, liver injury, and heart damage. JID Mar 17, 2020 on line

  19. Dong Y, Mo X, Hu Y, et al.Epidemiological characteristics of 2,143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020:e20200702. doi: 10.1542/peds.2020-0702

  20. Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T. Coronavirus disease 2019 in children – United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. Apr 10, 2020;69:(14):422-426. Doi: 10.15585/mmwr.mm6914e4