Signs and symptoms

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Most children with SARS-CoV-2 infection are asymptomatic or develop mild COVID-19 disease.96,97

Fever or chills and cough are the most common reported symptoms in children.97,98 Other symptoms include; shortness of breath, myalgia, rhinorrhoea, sore throat, nausea and vomiting, headache, abdominal pain, diarrhoea and loss of smell or taste.86,87,97 

Gastrointestinal symptoms may occur without respiratory symptoms, the most common being diarrhoea, vomiting, and abdominal pain.99-101

Less commonly reported symptoms include thoracic pains, somnolence, febrile convulsions, lower limb pains, ocular manifestations consistent with viral conjunctivitis and thrombotic sequelae.89 

Cutaneous findings have been reported infrequently and are not well characterised; they include maculopapular, urticarial, and vesicular eruptions; transient livedo reticularis; and acral peeling. Reddish-purple nodules on the distal digits (sometimes called "COVID toes") similar in appearance to pernio (chilblains) are described predominantly in children and young adults, although an association with COVID-19 has not been clearly established.102 

There appears to be little in the way of clinical signs in children to differentiate COVID-19 from other childhood respiratory virus infections, and COVID-19 has been detected in combination with other viral and bacterial infections.89 The Royal College of Paediatrics and Child Health (RCPCH) has issued national guidance for the management of children with bronchiolitis and lower respiratory tract infections during COVID-19:103 (https://www.rcpch.ac.uk/resources/national-guidance-management-children-bronchiolitis-during-covid-19#background).

Severe COVID-19 in children is rare. Symptoms in severe disease may include cardiovascular abnormalities (eg heart failure, arrhythmias, myocarditis, pericarditis, cardiogenic shock, pulmonary embolism, ST elevation myocardial infarction)84 and neurological manifestations (eg status epilepticus, encephalitis/encephalopathy, Guillain-Barré syndrome, acute demyelinating syndrome, chorea, psychosis, and transient ischaemic attack).104,105 

The RCPCH has produced a case definition for the paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS).106 A UK retrospective observational study of 78 cases meeting the RCPCH definition and admitted to paediatric intensive care units, reported that fever (100% of patients), shock (87%), abdominal pain (62%), vomiting (63%), and diarrhoea (64%) were common presenting features.107 Rash was seen in 45% of patients and conjunctivitis in 29% of patients. Only 3% of patients had comorbidities which would have been expected to require secondary care and 78% had no known comorbidities. There was an absence of significant respiratory involvement, also noted in international cases.108 An additional case series from the UK highlighted the wide spectrum of presenting symptoms and, in comparison with Kawasaki disease, suggests PIMS-TS differs from other paediatric inflammatory entities.109