COVID-19 - research evidence summaries - RCPCH

COVID-19 - research evidence summaries
Research & Evidence team
Here we provide a summary of key current evidence regarding COVID-19 in children and
young people.
Last modified
14 July 2020
Post date
9 April 2020
Table of contents

     Clinical features and investigations
     At risk groups
     Next steps

This summary is based on published and pre-print studies identified in our rapid review. As
evidence is rapidly emerging the content of this page will be reviewed and updated regularly,
the search strategy and inclusion criteria used to identify papers between 1 January and 30
June can be downloaded below.

This summary was last updated on 8 July 2020.

To get an email notification of updates to this page, log in and click or tap on the pink button
in the grey box above, 'Notify me when updated'.

Note: Some included studies, indicated in the reference list [*], provide preliminary findings
that have not yet been certified by peer review; these findings should be treated with due
Can children and young people suffer from COVID-19 disease?

COVID-19 disease has been reported in children and young people of all ages, including
shortly after birth.1 2 3 There have been far fewer confirmed cases of COVID-19 disease in
children than adults (children consistently make up 1-5% of total case numbers in reports).4 5
 6 7 8 9 10 11

We cannot be certain how many children in the community have been infected by SARS-
CoV-2 in the absence of widespread, high quality sero surveillance studies, but it seems
increasingly likely that there are comparatively few children infected by SARS-CoV-2 and
thus suffering from COVID-19 disease in the community.4 12 13 14

Does COVID-19 affect children and young people in the same way as adults?

Infection with SARS-CoV-2 appears to take a milder course in children than in adults: most
infected children present with mild symptoms or are asymptomatic,1 4 8 15 16 17 18 19 20
and very few (c. 1%) develop severe or life threatening disease.9 21 22 23 In the absence of
widespread community or serological testing, it is uncertain what the proportion with sub-
clinical symptoms is.

Deaths in children due to COVID-19 have been extremely rare: mortality seems to be
consistent at around 0.01% (similar to the incidence seen every year with seasonal
influenza).15 21

Are children as likely as adults to acquire COVID-19?

Emerging evidence suggests that children may be less likely to acquire the disease.4 12 13
21 24 25 26 27 28 29 30 31 32 This is supported in countries that have undertaken
widespread community testing, and serosurvey data, where significantly lower case numbers
in children than adults have been found.4 13 33

Can children transmit the virus?

The importance of children in transmitting the virus is difficult to establish, in particular given
the number of asymptomatic cases,34 but there is some evidence that their role in
transmitting the virus is limited. Precise details regarding paediatric transmission cannot be
confirmed without widespread sero surveillance, but trends are emerging. Studies of multiple
family clusters have revealed children were unlikely to be the index case, in Guangzhou,
China, Israel and other countries.30 35 36 37 38 39 40 A SARS-CoV-2 positive child in a
cluster in the French Alps did not transmit the virus to anyone else, despite exposure to more
than 100 people.41

There is some evidence of asymptomatic transmission from children to others.12 30

In the Netherlands, separate data from primary care and household studies suggests SARS-
CoV-2 is mainly spread between adults and from adult family members to children.14

An epidemiological study where 1155 contacts of six COVID-19 positive cases in an Irish
school were screened, there was no evidence of secondary transmission of COVID-19 from
children to other children or adults.42

This is a rapidly developing area and current published findings may be out of date. We will
update this as soon as further information becomes available.

What is the duration of viral shedding in nasopharyngeal or throat swabs?

The duration of viral shedding (in naso-pharyngeal or throat swabs) has been reported in
children to range from 6-22 days,43 44 with mean reported at 12 days43 vs. median eight

Can children transmit the virus through their stool?

Several studies have now shown that SARS-CoV-2 can be detected by PCR in the stool of
affected infants for several weeks after symptoms have resolved; faecal swabs have been
found to be positive for a longer duration than nasal swabs,44 45 46 with stool shedding
reported to be more than 30 days.47 48 This has raised the possibility of faecal-oral
transmission. Research from Germany did not identify any live, culturable virus in stool
despite viral RNA being detectable, suggesting this represents viral debris rather than active

Subsequent reports, however, indicate that there has been infectious virus in stool identified,
50 but how much and how infectious is not yet clear as it is not quantified. This would
suggest that faecal-oral transmission theoretically is possible but we would need more
evidence to really know the ramifications of this. Hand hygiene remains essential to reduce
the spread of the virus from droplets arising from either the respiratory or GI tract. Further
studies are needed.

Clinical features and investigations
What are the symptoms of COVID-19 disease?

Disease presentation can range from no symptoms (asymptomatic) to severe pneumonia
requiring ITU admission.18 51 52 53 54 55 When there are clinical features, they are non-
specific and similar to other viral respiratory infections. The most common presenting
features, present in more than 50% of cases, are cough and fever; upper respiratory tract
symptoms (such as sore throat and rhinorrhoea) occur in 30-40% of patients; diarrhoea and
vomiting present in approximately 10% of cases.1 5 23 43 44 48 49 51 54 56 57 58 59 60 61
62 63 64 65 66 There are reports of infants presenting with fever but no respiratory
symptoms.67 Less commonly reported symptoms include thoracic pains, somnolence, febrile
convulsions, lower limb pains20 and ocular manifestations consistent with viral conjunctivitis.

Differences in immune responses may play a role in influencing the severity of symptoms.69
Please see 'Can SARS-CoV-2 trigger a Kawasaki like syndrome' below for further
information about the symptoms of the hyper-inflammatory response syndrome.

Are there any signs that could help differentiate COVID-19 from other childhood
respiratory viral infections?

There appears to be little in the way of clinical signs in children to differentiate COVID-19
from other childhood respiratory virus infections. There have not been any firm descriptions
of wheeze with COVID-19 in the literature so far.

There are some cases indicating possible association with skin manifestations70 in patients
with suspected or confirmed COVID-19 (but please note, this case series does not describe
the age of patients so includes adults), which may persist for some time once other
symptoms have resolved and include acral areas of erythema oedema with some vesicles or
pustules, other vesicular eruptions, urticarial lesions, other maculopapular lesions, livedo or
necrosis. Dermatological exanthem,71 papularmacular72 and chilblain like lesions
associated with COVID-19 have also been reported in children.73 74 75 The finding of the
presence of SARS-CoV-2 in the endothelium of dermal vessels in skin biopsies of children
and adolescents with acute chillblains confirms that these (chillblain) lesions are a
manifestation of COVID-19.76

Can SARS-CoV-2 trigger a Kawasaki like syndrome?

An emerging phenomenon of a hyperinflammatory response syndrome, resembling
Kawasaki shock, was reported in a case study describing a six month old who was treated
for Kawasaki's and then subsequently was found to test positive for SARS-CoV-2.77 Further
studies were reported in the UK,78 79 including a case series indicating that it can mimic
appendicitis, with inflammation of the terminal ileum,80 Italy81 82 and France,83 as well as
the US65 84 85 86 87 88 and Luxembourg.89

The RCPCH have produced a case definition for this Paediatric multi inflammatory
syndrome temporally associated with SARS-CoV-2 (PIMS-TS) which can be found here. The
CDC have subsequently named the same syndrome Multisystem Inflammatory Syndrome in
children (MIS-C) with a slightly different case definition.

Symptoms reported include abdominal pain, vomiting and diarrhoea, with persistent high-
grade fever and frequently progress to shock with cardiac involvement requiring ICU
admission for inotropic support, mechanical ventilation and, in a small number of patients,
ECMO.90 91 92 93 Children tend to have high inflammatory markers, cardiac involvement,94
e.g. myocarditis,95 macular papular rashes and non-suppurative conjunctivitis.93 96 There
have been a handful of fatalities reported.97

A possible temporal association with SARS-CoV-2 infection has been hypothesised because
some of the children that were tested for SARS-CoV-2 infection were either positive by PCR
or serology. The first epidemiological surveillance study of PIMS-TS in France supports a
casual link with COVID-19 following four-five weeks behind the clinical illness.98

One of the most detailed reports of 58 children diagnosed with PIMS-TS demonstrate that it
can have a wide spectrum of symptoms, signs and severity and overlap with Kawasaki
Disease (KD), KD shock syndrome (KDSS) and toxic shock syndrome (TSS). Differences in
clinical and laboratory profile compared with KD, KDSS and TSS suggest that PIMS-TS is a
unique entity, potentially arising from a maladaptive acquired immune response to the SARS-
CoV-2 infection.93

Further information can be found on the management of children presenting like this. The
document details information on how to include cases you might be managing into research
studies, such as the DIAMONDS study.

Are children from a BAME background at a higher risk of severe disease from acute
COVID-19 infection?

Children from a BAME background seem to be at higher risk of severe disease from acute
COVID-19,99 which is consistent with adult literature. BAME children are significantly over-
represented in case reports/series of PIMS-TS.82 93

How long after being exposed to SARS-CoV-2 does a child develop symptoms?

The assumed incubation period (time from exposure to index case to developing symptoms)
varies in different studies: it has been reported to be between 2-10 days, with median (and
mode) of seven days,47 vs. 24h – 28d,63 vs. mean of 10 days (IQR 7.75 – 25.25).62

Can a child be asymptomatic but still have COVID-19?

Yes, there are reports of asymptomatic cases with positive laboratory confirmed COVID-19.
15 23 35 57 100 101 In the absence of widespread community or serological testing, it is
uncertain what proportion of children do not have any symptoms or have sub-clinical
symptoms. Testing of 120 asymptomatic cancer patients in a US cancer centre revealed
2.5% to be positive (vs. 14.7% of their care givers).29

What are blood and imaging tests of children with COVID-19 likely to show?

Laboratory findings are non-specific, and often normal. They may include slightly elevated
inflammatory markers including c-reactive protein,23 and raised liver transaminases.43 57
Lymphocytopenia is seen,3 63 102 but more children appear to have raised or normal
lymphocyte counts.36 43 53 54 57 103 104

Radiological investigations in infected children are also often normal.43 61 64 However,
findings may include features consistent with pneumonia such as ground glass opacities20
43 57 102 105 106 107 108 or consolidation56 64 (commonly bilateral, but with less
peripheral predominance than is reportedly found in adults) and CT changes have been
found in asymptomatic positive children.103

There are several cases of reported co-infection of SARS-CoV-2 and other respiratory
viruses, which illustrates that the identification of another respiratory pathogen should not
preclude SARS-CoV-2 testing in children.

If a swab is negative for COVID-19 infection is it possible that a child has COVID-19

We know that virtually no test is perfectly sensitive (correctly picks up all people with the
disease) or specific (correctly picks up all people who don’t have the disease) and the same
is true for COVID-19. The test that is used to confirm whether someone has COVID-19
infection or not uses swabs from the back of the nose and throat. These are used to look for
COVID-19 genetic material in the cells that have been picked up, using a technique called
reverse transcriptase polymerase chain reaction (RT-PCR). It is possible to still have COVID-
19 infection even if the RT-PCR does not detect COVID-19 genetic material, particularly very
early or very late in the disease.109 We don’t yet know exactly how sensitive or specific the
RT-PCR test is at detecting COVID-19 but if there is a high clinical suspicion of infection if a
second swab improves the sensitivity. RT-PCR does not tell you if a child has been infected
with COVID-19 in the past.

Blood tests are being developed to detect whether someone has or has had COVID-19
infection. These have not yet been validated and are not currently in use in the UK. Once
they come into general use, they will give more information about the sensitivity and
specificity of the swabs and how many people have had COVID-19 infection already.

At risk groups
Are there any groups that are at higher risk of developing severe COVID-19 illness?

There is some evidence reflecting a small increased risk of children with comorbidities
needing hospitalisation or intensive care admission from COVID-19.110 Reports of children
with immunosuppression or cancer therapy have not shown it to be a significant risk factor
for severe disease.111 112 113 114 115 116 117 Contact tracing on a dialysis unit who had
contact with a member of staff who tested positive found three children to be positive, but
only one had symptoms.118 A case report of a child with cystic fibrosis who contracted
COVID-19 from his grandfather, identified though contact tracing, also remained
asymptomatic.119 There is a case report of COVID-19 pneumonia triggering acute chest
syndrome in an adolescent with known sickle cell disease on daily hydroxyurea.120

On screening patients and caregivers with cancer in one of the largest paediatric cancer
centres in the US, 20 of 178 paediatric patients tested positive. Only one (5%) required
hospitalisation for symptoms of COVID-19, with none requiring critical care.29

CDC data from the USA reports that a high proportion of cases needing admission had at
least one co-morbidity (most commonly respiratory).5 Further data from Italy18 and the US65
 also finds that children with co-morbidities are over represented in those admitted to
hospital, though most were reported to have mild illness. Notably there is no apparent
difference in severity according to age in the Italian data, whereas CDC data5 noted
increased hospitalisation in infants (under one year of age) and Dong et al101 noted higher
rates of severe or critical illness infants under one year of age.

The RCPCH have provided guidance for the need for shielding in certain groups. This
guidance continues to be reviewed as new evidence emerges.

What are the characteristics of children admitted to PICU?

Severe illness is far less frequent in children than adults, but it is still significant in a very
small number of children and young people.121

Data on PICU admissions in Italy showed a higher proportion of those admitted to ITU had a
co-morbidity (3 out of 4 children needing ICU admission in this case series).52
In a cross sectional study of 46 North American PICUs,122 48 children were admitted to 14
PICUs, with a median age of 13 (4.2 to 16.6). Most presented with respiratory symptoms but
there were other presentations, such as with vaso-occlusive crisis (sickle cell) and diabetic
ketoacidosis. A total of 40 children (83%) had at least one pre-existing underlying medical
condition. The most common comorbidity was medically complex, defined as children who
had a long-term dependence on technological support (including tracheostomy) associated
with developmental delay and/or genetic abnormalities. Of those, 20% (aged six years or
older) had obesity, 38% required invasive ventilation. Extra corporeal membrane
oxygenation was required for one patient (2%). Two children died, so the overall ICU
mortality rate was
indicate intrauterine transmission but this is not clear because these babies tested negative
on swab PCR and false positives with IgM are not uncommon.148 149 There have also been
cases of newborns and very young infants testing positive shortly after birth (including several
129 150 at or before 12 hours of age)2 127 151 however they have not suffered any known
significant complications of the disease and mostly required minimal respiratory support.

Can the virus be transmitted or through breast milk?

Many reports of breast milk from COVID-19 positive mothers found that the breastmilk tested
negative for COVID-19.3 113 128 144 152 153

There are a small number of reports of viral RNA being found in breast milk,154 155 but it is
unclear if this positive result reflects live, infectious virus and whether the source was the
mother or infant who subsequently tested positive for the virus.

Subsequent data suggests pasteurisation eliminates the virus from breast milk and also that
PCR positive breast milk does not seem to represent live, replicating virus.156 Further large
scale studies are needed to draw firm conclusions.

WHO continues to recommend breastfeeding with appropriate precautions for COVID-19
positive mothers.

Does having COVID-19 in pregnancy cause any long-term problems for the baby?

We do not currently have sufficient evidence to draw conclusions on this.

What treatments are available for children with COVID-19?

For those without severe disease, which will be most children, supportive management
(ensuring oxygenation, hydration and nutrition) is appropriate. For more information, please
see the RCPCH guidance on the clinical management of children admitted to hospital with
suspected COVID-19.

There are no proven beneficial drugs for COVID-19. There are many ongoing studies: with
the UK, there is the RECOVERY trial which is now recruiting neonates and children who are
severely unwell with COVID-19. There are four 'arms' (Hydroxychloroquine, Azithromycin,
Lopinavir-Ritonavir and Corticosteroid) to the study and children could receive any one of
these treatments IF it is suitable for them (i.e. their clinical picture, other medications and any
co-morbidities). There is some evidence that Remdesivir, another anti-viral treatment, may
improve time to clinical improvement in adults157 and is available for use in children (but not
part of the RECOVERY trial).

Treatment strategies for PIMS-TS are currently under review but therapies that have been
employed to date include high dose steroids, Intravenous Immunoglobulin and biological
therapies including Anakinra and Tocilizumab.

What studies are enrolling children currently to therapeutic trials?

For those who develop more severe or critical illness (RCPCH treatment criteria), please
consider enrolment in the RECOVERY trial. This study is open at many sites including
hospitals with and without on-site PICU, and from 11 May will be including children down to
those just born. It also includes those with PIMS-TS.

If you are considering entering a child to RECOVERY, we suggest you check with your
Regional Infectious Disease team and watch the relevant video(s) and view the FAQs on the
study website. Please note that there are separate training videos in respect to children and
infants of less than 29 days of age. If you are still uncertain about eligibility, there is the
possibility for you to contact an 'on-call' member of the study team to discuss further, but
please only do this if you are particularly uncertain.

If you think entry into RECOVERY is indicated, it can take place in the hospital where the
child is admitted - you don't have to wait for them to be transferred to a regional centre.

Is it safe to give ibuprofen to a child who has tested positive for COVID-19 or is highly
likely to be positive?

There is currently insufficient evidence to establish a link between use of ibuprofen, or other
nonsteroidal anti-inflammatory drugs (NSAIDs), and contracting or worsening of COVID-19.
Whilst an early report suggested ibuprofen was associated with poorer outcomes,
subsequent work has not supported this. The RCPCH has made a statement about the use
of ibuprofen in suspected/confirmed COVID-19. It remains a very powerful, safe and effective
medicine for reducing fever and pain in infants, children and young people and adults.

Is there an effective vaccine?

Vaccines will hopefully provide protection against future outbreaks of COVID-19, though
these are still early in the drug development pipeline and unlikely to be available this year.

What is the prognosis of a child who has had COVID-19?

The short-term prognosis in those who recover appears to be good with both infants158 and
children largely appearing to make a full recovery.23 159

Are there any long-term complications (in specific groups) such as reduced exercise
tolerance, developmental delay, or worsening of cardiac function?

We do not currently have sufficient evidence to draw any conclusions on this.

In children, the evidence is now clear that COVID-19 is associated with a considerably lower
burden of morbidity and mortality compared to that seen in the elderly. There is evidence of
critical illness and death in children, but it is rare.
There is also some evidence that children may be less likely to acquire the infection. The role
of children in transmission, once they have acquired the infection, is unclear, although there
is no clear evidence that they are any more infectious than adults.

Symptoms are non-specific and most commonly cough and fever. Laboratory and
radiological investigations may be normal or mildly altered.

There is some possible evidence of infection in newborns which could indicate vertical
transmission, but it is not clear if this is intrauterine or perinatal. Early evidence suggests
both infected mothers and newborns are not particularly more severely affected than other

Children with co-morbidities, notably respiratory and complex neurodisability, appear more
likely to suffer complications and need hospital +/- PICU admission, but not obviously more
than would be expected from infection with other respiratory viruses.

Delayed access to care and late presentations, due to concerns over SARS-CoV-2 infection,
have been observed in an Italian case series160 and a BPSU snap-shot survey.161 There is
significant mobidity and mortality reported as a consequence of the pandemic.

Next steps
We will continue to collate and summarise the evidence around COVID-19 and children and
young people as it emerges, in partnership with The Don’t Forget the Bubbles team. A
comprehensive summary of all the papers identified on COVID-19 and children published to
date is hosted by Don’t Forget the Bubbles.

     1. a. b. c. Qiu H, Wu J, Hong L, et al. Clinical and epidemiological features of 36
     children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an
     observational cohort study. The Lancet Infectious Diseases. 2020.
     2. a. b. Yu N, Li W, Kang Q, et al. Clinical features and obstetric and neonatal
     outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-
     centre, descriptive study. The Lancet Infectious Diseases. 2020.
     3. a. b. c. 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. JAMA
     Pediatrics. 2020.
     4. a. b. c. d. e. Choe YJ. Coronavirus disease-19: The First 7,755 Cases in the
     Republic of Korea. Osong Public Health and Research Perspectives. 2020.
     5. a. b. c. d. CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children -
     United States, February 12-April 2, 2020. MMWR Morbidity and mortality weekly report.
     Centers for Disease Control and Prevention. 2020.
6. Tagarro A, Epalza C, Santos M, et al. Screening and Severity of Coronavirus
Disease 2019 (COVID-19) in Children in Madrid, Spain. JAMA Pediatrics. 2020.
7. Livingston E, Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. Jama. 2020.
8. a. b. World Health Organisation. Report of the WHO-China Joint Mission on
Coronavirus Disease 2019 (COVID-19). 2020.
9. a. b. Wu Z, McGoogan JM. Characteristics of and important lessons from the
coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72
314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020.
10. Xiao Z, Xie X, Guo W, et al. Examining the incubation period distributions of COVID-
19 on Chinese patients with different travel histories. The Journal of Infection in
Developing Countries
11. de Lusignan S, Dorward J, Correa A, et al. Risk factors for SARS-CoV-2 among
patients in the Oxford Royal College of General Practitioners Research and
Surveillance Centre primary care network: a cross-sectional study. The Lancet
Infectious Diseases
12. a. b. c. *Lavezzo E, Franchin E, Ciavarella C, et al. Suppression of COVID-19
outbreak in the municipality of Vo, Italy. medRxiv 2020.
13. a. b. c. Gudbjartsson D, Helgason A, Jonsson H, et al. Spread of SARS-CoV-2 in
the Icelandic Population. The New England Journal of Medicine 2020.
14. a. b. National Institute for Public Health and the Environment. Children and COVID-
19. 2020.
15. a. b. c. Bi Q, Wu Y, Mei S, et al. Epidemiology and Transmission of COVID-19 in
Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts. Lancet
Infectious Diseases
16. Kam KQ, Yung CF et al. A well infant with coronavirus disease 2019 (COVID-19)
with high viral load. Clinical Infectious Diseases. 2020.
17. *Tang A, Xu W, Shen M, et al. A retrospective study of the clinical characteristics of
COVID-19 infection in 26 children. medRxiv. 2020.
18. a. b. c. Parri N, Lenge M, Buonsenso D. Children with Covid-19 in Pediatric
Emergency Departments in Italy. The New England Journal of Medicine. 2020.
19. Wu Q, Xing Y, Shi L, et al. Co-infection and Other Clinical Characteristics of COVID-
19 in Children. Paediatrics 2020.
20. a. b. c. Parri N, Magistà AM, Marchetti F, et al. Characteristic of COVID-19 infection
in pediatric patients: early findings from two Italian Pediatric Research Networks.
European Journal of Pediatrics. 2020.
21. a. b. c. *Davies NG, Klepac P, Liu Y, et al. Age-dependent effects in the
transmission and control of COVID-19 epidemics. medRxiv 2020.
22. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics,
Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the
New York City Area. Jama
23. a. b. c. d. e. Garazzino S, Montagnani C, Donà D, et al. Multicentre Italian study of
SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April
2020. Eurosurveillance 2020; 25(18): 2000600.
24. *Jing QL, Lui MJ, Yuan J, et al. Household Secondary Attack Rate of COVID-19
and Associated Determinants. medRxiv. 2020.
25. *Mizumoto K, Omori R, Nishiura H. Age specificity of cases and attack rate of novel
coronavirus disease (COVID-19). medRxiv 2020.
26. Zhang J, Litvinova M, Liang Y, et al. . Changes in contact patterns shape the
dynamics of the cOVID-19 outbreak in China. Science. 2020.
27. Wang Z, Ma W, Zheng X, et al. Household transmission of SARS-CoV-2. Journal of
Infection. 2020.
28. COVID-19 National Emergency Response Center. Coronavirus Disease-19:
Summary of 2,370 Contact Investigations of the First 30 Cases in the Republic of
Korea. Osong Public Health and Research Perspectives. 2020.
29. a. b. c. Boulad F, Kamboj M, Bouvier N, et al. COVID-19 in Children With Cancer in
New York City. Jama
30. a. b. c. Li W, Zhang B, Lu J, et al. The characteristics of household transmission of
COVID 19. Clinical Infectious Diseases 2020.
31. National Centre for Immunisation Research and Surveillance. COVID-19 in schools
– the experience in NSW.
32. Rosenberg ES, Dufort EM, Blog DS, et al. COVID-19 Testing, Epidemic Features,
Hospital Outcomes, and Household Prevalence, New York State-March 2020. Clinical
Infectious Diseases. 2020.
33. *Pagani G, Conti F, Giacomelli A, et al. Seroprevalence of SARS-CoV-2 IgG
significantly varies with age: results from a mass population screening (SARS-2-
SCREEN-CdA). medRxiv 2020.
34. Zimmerman P, Curtis N. Coronavirus infections in children including COVID-19. An
overview of the epidemiology, clinical features, diagnosis and prevention options in
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35. a. b. Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a family cluster with
SARS-CoV-2 infection. The Lancet Infectious Diseases 2020; 20(4): 410-1.
36. a. b. Ji LN, Chao S, Want Y, et al. Clinical features of pediatric patients with COVID-
19: a report of two family cluster cases. World Journal of Pediatrics 2020.
37. Song R, Han B, Song M, et al. Clinical and epidemiological features of COVID-19
family clusters in Beijing, China. Journal of Infection. 2020.
38. *Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the
primary source of household SARS-CoV-2 infections. medRxiv. 2020.
39. Posfay-Barbe KM, Wagner N, Gauthey M, et al. COVID-19 in Children and the
Dynamics of Infection in Families. Pediatrics. 2020.
40. Somekh E, Gleyzer A, Heller E, et al. The Role of Children in the Dynamics of Intra
Family Coronavirus 2019 Spread in Densely Populated Area. The Pediatric Infectious
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41. Danis K, Epaulard O, Benet T, et al. Cluster of coronavirus disease 2019 (Covid-
19) in the French Alps, 2020. Clinical Infectious Diseases. 2020.
42. Heavey L, Casey G, Kelly C, et al. No evidence of secondary transmission of
COVID-19 from children attending school in Ireland, 2020. Euro surveillance. 2020.
43. a. b. c. d. e. f. g. Cai J, Xu J, Lin D, et al. A Case Series of children with 2019 novel
coronavirus infection: clinical and epidemiological features. Clinical Infectious
Diseases. 2020.
44. a. b. c. d. De Ioris MA, Scarselli A, Ciofi degli Atti ML, et al. Dynamic viral SARS-
CoV-2 RNA shedding in in children: preliminary data and clinical consideration of Italian
regional center. Journal of the Pediatric Infectious Diseases Society 2020.
45. Han MS, Seong MW, Heo EY, et al. Sequential Analysis of Viral Load in a Neonate
and Her Mother Infected With Severe Acute Respiratory Syndrome Coronavirus 2.
Clinical Infectious Diseases. 2020.
46. Zhang B, Liu S, Dong Y, et al. Positive rectal swabs in young patients recovered
from coronavirus disease 2019 (COVID-19). Journal of Infection 2020.
47. a. b. Cruz AT, Zeichner SL. COVID-19 in Children: Initial Characterization of the
Pediatric Disease. Pediatrics. 2020.
48. a. b. Xu, Y., Li, X., Zhu, B. et al. Characteristics of pediatric SARS-CoV-2 infection
and potential evidence for persistent fecal viral shedding. Nature Medicine. 2020.
49. a. b. Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al.
Virological assessment of hospitalized patients with COVID-2019. Nature Medicine.
50. Xiao F, Sun J, Xu Y, et al. Infectious SARS-CoV-2 in Feces of Patient with Severe
COVID-19. Emerging Infectious Disease Journal 2020; 26(8).
51. a. b. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. New England
Journal of Medicine
52. a. b. Grasselli G, Zangrillo A, Zanella A, et al. Baseline Characteristics and
Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the
Lombardy Region, Italy. Jama. 2020.
53. a. b. Canarutto D, Priolo A, Russo G, et al. COVID-19 infection in a
paucisymptomatic infant: Raising the index of suspicion in epidemic settings. Pediatric
Pulmonology. 2020.
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