Clinical and epidemiological characteristics of pediatric SARS-CoV-2 infections in China: A multicenter case series

Che Zhang , Jiaowei Gu , Quanjing Chen, Na Deng, Jingfeng Li, Li Huang , Xihui Zhou



As of April 18, 2020, over 2,000,000 patients had been diagnosed with coronavirus disease-2019 (COVID-19) globally, and more than 140,000 deaths had been reported. The clinical and epidemiological characteristics of adult patients have been documented recently. However, information on pediatric patients is limited. We describe the clinical and epidemiological characteristics of pediatric patients to provide valuable insight into the early diagnosis and assessment of COVID-19 in children.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has spread worldwide rapidly since its emergence in Wuhan in China in early December 2019 [1]. The SARS-CoV-2 epidemic was declared a public health emergency of international concern by the World Health Organization (WHO) on January 30, 2020 [2]. To date, over 2,000,000 patients have been diagnosed with coronavirus disease-2019 (COVID-19) globally. The cumulative number of laboratory-confirmed cases has been reported to be over 660,000 in the United States, 180,000 in Spain, 170,000 in Italy, and 80,000 in China [3]. SARS-CoV-2 was identified as a diverse clade derived from severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) and was reported as the cause of COVID-19 [4]. The clinical characteristics of adult patients with COVID-19 have been revealed in recent studies and mainly include fever, cough, dyspnea, and radiographic findings of pneumonia [5–7]. However, information on pediatric patients is limited. This case series describes the clinical and epidemiological features of 34 pediatric patients on the basis of epidemiological, demographic, laboratory, and radiological data and aims to contribute to a comprehensive understanding of the characteristics of COVID-19.


Study design and participants

This retrospective, observational study was approved by the institutional review board (IRB) of the Affiliated Taihe Hospital of Hubei University of Medicine (ethical approval no. 2020KY01). Suspected patients with clinical and/or radiological features of pneumonia were quarantined prior to SARS-CoV-2 nucleic acid detection according to WHO guidelines for cases with suspected infection [8] as well as the instructions from the Pediatric Branch of the Hubei Medical Association for pediatric cases [9]. Specifically, suspected cases of SARS-CoV-2 infection should meet 1 of the following criteria [10]: (1) at least 1 clinical symptom, including fever, expectation, tachypnea, lethargy, poor feeding, cough, vomiting, and diarrhea; (2) chest radiologic abnormalities consistent with viral pneumonia. Diagnosis was confirmed by the SARS-CoV-2 nucleic acid test with samples from respiratory tract swabs. Admitted children with laboratory-confirmed SARS-CoV-2-positive results from 4 hospitals in West China from January 27 to February 23, 2020, were included. The clinical type of disease (S1 Table) was assessed for each patient according to the recommendation of the National Health Commission of the People's Republic of China (NHC) [10]. Patients were discharged when all the following criteria were met [10]: (1) fever had recovered for at least 3 days; (2) upper respiratory symptoms were alleviated; (3) the exudative lesion was alleviated significantly according to radiological evidence; (4) negative results were obtained for SARS-CoV-2 nucleic acid detection in 2 consecutive tests performed with an interval of 24 hours. The final follow-up visit was completed by March 16, 2020. Assent was gained from school-aged children, and written informed consent was provided by their parents or guardians prior to data collection. There was no prespecified protocol prior to the current study. The clinical process and data analysis plan are shown in Fig 1.


Along with the rapid spread of SARS-CoV-2 infection, the pediatric cases of COVID-19 gradually increased. The morbidity of COVID-19 in children was reported as 0.9% in China [1], 1.2% in Italy [12], and 5% in the USA [13]. However, the clinical and epidemiological characteristics of pediatric patients have not yet been determined clearly. Here, we report the clinical and epidemiological features of 34 pediatric patients with COVID-19 aged from 1 to 144 months. Patients experienced mild or moderate disease forms in the current study. Most patients suffered from fever and cough, which recovered within 3.00–4.00 days after treatment. The progression pattern of the lesions in lobules was revealed by chest CT scan, and the lesions still existed in the majority of patients when discharged. Unlike other reports, the typical feature of ground-glass opacity observed in adults was rare in pediatric patients based on our data. Substantial increases were detected in SSA, hs-CRP, LDH, and α-HDBD, all of which recovered promptly after treatment.
Citation: Zhang C, Gu J, Chen Q, Deng N, Li J, Huang L, et al. (2020) Clinical and epidemiological characteristics of pediatric SARS-CoV-2 infections in China: A multicenter case series. PLoS Med 17(6): e1003130.

Academic Editor: Lars Åke Persson, London School of Hygiene and Tropical Medicine, UNITED KINGDOM

Received: March 6, 2020; Accepted: May 13, 2020; Published: June 16, 2020

Copyright: © 2020 Zhang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CK, creatine kinase; CK-MB, creatine kinase-MB; COVID-19, coronavirus disease-2019; CT, computed tomography; ECG, electrocardiogram; ESR, erythrocyte sedimentation rate; hs-CRP, high-sensitivity C-reactive protein; IQR, interquartile range; IRB, institutional review board; LDH, lactate dehydrogenase; MERS-CoV, Middle East respiratory syndrome coronavirus; NHC, National Health Commission of the People’s Republic of China; PACS, picture archiving and communication systems; RT-PCR, real-time reverse transcription polymerase chain reaction; SAA, serum amyloid A; SARS-CoV, severe acute respiratory syndrome coronavirus; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; WHO, World Health Organization; α-HBDH, α-hydroxybutyrate dehydrogenase.