doi:10.1111/jpc.
14872
COMMENTARY
Questions raised by COVID-19 case descriptions
The recent emergence and rapid spread of COVID-19 in Wuhan,
China pose an ongoing global challenge. An intriguing observa-
tion has been the near absence of children in initial disease
reports, mild disease overall in child cases, no reported deaths in
children aged <10 years of age and suggestions that minimally
symptomatic children may facilitate disease transmission within
communities.1–6 Li et al. report three child cases of confirmed
COVID-19 infection7; the report is notable for at least two
reasons.
Firstly, the report describes a mild disease course amongst
young children with no symptoms of respiratory distress, no clin-
ical indication for hospitalisation, minimal changes on chest com-
puted tomography and complete recovery in the short term. This
raises multiple questions such as: (i) whether the low frequency
of confirmed COVID-19 infections in children reflects case detec-
tion bias due to attenuated disease severity in children;
(ii) whether undiagnosed child infections contribute to commu-
nity transmission; (iii) the biological basis for the attenuated dis-
ease severity, if this is indeed the case; and (iv) the role of
existing co-morbidity in children, given indications that – as well
as older age – co-morbidity is a major determinant of disease
severity in adults.2,8
Secondly, the report describes the use of nebulised interferon-
α in two cases, with to our knowledge no data on efficacy and
limited information on safety, while nebulisation poses a trans-
mission risk in healthcare environments, as observed with the
nearly identical SARS coronavirus.9 While the use of novel/
experimental therapies may be justified in a desperate situation,
every indication is that this is not required in young children
with minimal symptoms. The imperative to ‘do anything possible’
will be felt by all paediatricians caring for children with COVID-
19; however, the ‘first do no harm’ principle should certainly
apply in all situations where the natural history of disease is
poorly described or indicative of likely spontaneous recovery
without any treatment. Clinicians should always balance poten-
tial risks and benefits to the individual patient with assiduous
attention to infection control to protect other vulnerable patients
within the health-care environment and the public at large.
The report by Li et al.7 is valuable given the scant information
available on children with COVID-19, but detailed case descrip-
tions with better documentation of the full disease course would
have been more informative. Paediatricians around the world
should endeavour to collect comprehensive clinical data and
Correspondence: Dr Philip N Britton, The Children’s Hospital at
Westmead Clinical School, Locked Bag 4001, Westmead, NSW Australia,
2145. Fax: +612 9845 3291; email: philip.britton@health.nsw.gov.au
Journal of Paediatrics and Child Health (2020)
© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
biological specimens including longitudinal sampling from cases
wherever they occur in order to further our understanding of the
clinical features, pathogenesis of disease and host response in
children infected with COVID-19.
Dr Philip N Britton1,2
Professor Ben J Marais1,2
1
Sydney Medical School and Marie Bashir Institute for Emerging
Infectious Diseases and Biosecurity
University of Sydney
2
Department of Infectious Diseases and Microbiology
The Children’s Hospital at Westmead
Sydney, New South Wales
Australia
Accepted for publication 5 March 2020.
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