Coronavirus Symptoms in Children May Include Sickness and Diarrhea Rather Than Cough, Study Finds

Children with COVID-19 may not have respiratory symptoms at first, according to the authors of a small study who believe the disease can start with digestive problems in this age group.

The research, published in the journal Frontiers in Pediatrics, involved five children aged between two and five from Wuhan, the Chinese city that was the original epicenter of the COVID-19 pandemic. In four of these patients, the disease first manifested with digestive tract symptoms.

The children visited the emergency department of Wuhan Children's Hospital between January 23 and February 20, 2020, for problems unrelated to COVID-19, but later tested positive for the coronavirus at the facility. They had no respiratory symptoms, such as a cough, when they first arrived.

According to the authors, only one child was known to have been exposed to the coronavirus, while one had a suspected contact history.

The authors highlighted that as their COVID-19 progressed, four out of the five children had a fever. However, as the children had coexisting problems, it's not clear if the fever was due to those or their coronavirus infection. All of the children had CT chest scans, and showed signs of pneumonia—a complication of COVID-19.

One of the children, a 10-month-old girl, was vomiting, had stools resembling currant jelly when she arrived at the hospital, and developed a fever soon after. Nine days after visiting the emergency room, she had an enlarged abdomen and "dark-red bloody stools, and coffee dreg-like gastric contents." The child later died due to multiple organ failure.

The second child was a five-year-old with appendicitis. He didn't have signs or symptoms of COVID-19, but as his grandmother had the disease doctors performed a CT scan before the operation to treat his appendicitis. They found he had viral pneumonia, and he tested positive for the coronavirus. He recovered after 10 days.

The third case involved an 8-month-old baby who visited the emergency department after suffering head trauma three days prior. The baby, who had no known contact with a COVID-19 patient, developed a fever. Before being admitted to the pediatric intensive care unit, he had a chest CT scan that led doctors to believe he had COVID-19. He later tested positive, and was discharged after 14 days.

Case four became the first severe case of COVID-19 in a child in China, according to the authors. The one-year-old boy had been vomiting and suffering from diarrhea for six days before visiting the hospital. He also had a fever, was lethargic and had shortness of breath for half a day in the emergency observation room. The child had a history of kidney problems, and doctors initially thought he had a rotavirus infection. Like the other children, he had a CT scan that showed issues in his right and left lungs. The patient tested negative for coronavirus on the second and seventh day of his hospital stay, and positive on day eight. Soon after he was admitted, his blood oxygen saturation dropped rapidly and he was intubated and put on a ventilator. After 17 days, he was discharged.

The authors also described the case of a two-month-old boy whose parents said was drowsy and not feeding normally for three days, and had diarrhea for two, prior to visiting hospital. Although he had no COVID-19 symptoms, doctors performed a CT scan on his chest to check as his parents and grandparents were suspected of having the disease. Doctors found he had pneumonia in both lungs. He was admitted to hospital with suspected COVID-19, and discharged after 15 days.

The digestive symptoms the children had suggest the coronavirus not only infects patients through the respiratory tract, as the virus travels on droplets, but also the digestive tract, the authors said. This could happen if a person ingests feces, they said, and could be possible as "children are active and do not pay much attention to hand hygiene."

"Consequently, the likelihood of infection through the digestive tract by contact or fecal–oral transmission is likely to be significantly greater for children than for adults, and gastrointestinal symptoms as the first manifestation might be more common in children," they wrote.

The study was limited, the team acknowledged, for a variety of reasons, including that the coronavirus tests could have brought up false positives, and they didn't test the children's stool or blood samples. But due to the exposure history, chest CT scan results and other signs and symptoms of the patients, the team was "reasonably certain" the children were infected with the coronavirus.

The data collected so far on the disease which first came to the attention of health officials in the Chinese city of Wuhan late last year shows children generally develop mild or no COVID-19 symptoms, and deaths in this group are rare. Most of the children who fall seriously ill usually have underlying conditions, the authors said. Usually, kids recover after one to two weeks of their first symptoms showing.

Children may have a less serious form of COVID-19 because their immune systems are immature, the team explained. But as two participants who became severely ill had multiple organ problems, the virus may cause an overreaction of the immune systems, known as a cytokine storm.

Co-author Dr. Wenbin Li, of the Department of Pediatrics at China's Tongji Hospital in Wuhan, said in a statement: "It is easy to miss its diagnosis in the early stage, when a child has non-respiratory symptoms or suffers from another illness.

"Based on our experience of dealing with COVID-19, in regions where this virus is epidemic, children suffering from digestive tract symptoms, especially with fever and/or a history of exposure to this disease, should be suspected of being infected with this virus."

Li went on: "The gastrointestinal symptoms experienced by these children may be related to the distribution of receptors and the transmission pathway associated with COVID-19 infection in humans. The virus infects people via the ACE2 receptor, which can be found in certain cells in the lungs as well as the intestines. This suggests that COVID-19 might infect patients not only through the respiratory tract in the form of air droplets, but also through the digestive tract by contact or fecal-oral transmission."

According to Johns Hopkins University, more than 4.1 million people have been diagnosed with COVID-19 worldwide, 286,355 people have died since the pandemic started, and 1.4 million people are known to have recovered. As shown in the graph by Statista below, the U.S. is the country with the most known cases.

Coronavirus, Statista, Update
Number of cases of COVID-19 reported worldwide as of May 11. Statista