A Systematic Review of Gastrointestinal Manifestations in Children Presenting with COVID-19
Silvia Salvatore1, Massimo Agosti1, Serena Arrigo1, Marta Stracuzzi2, Dario Dilillo2, Laura Folgori2, Roberta Giacchero3, Vania Giacomet2, Emma Longoni2, Antonella Meini4, Gian Luigi Marseglia5, Alessandro Plebani4, Alessandro Ferdinando Ruffolo6, Lucia Barcellini2, Gianvincenzo Zuccotti2 and COVID-19 Pediatric network
1Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, Varese, Italy; 2Department of Pediatrics, Ospedale dei Bambini, University of Milan, ASST FBF SACCO, Milan, Italy; 3Department of Pediatrics, Ospedale Maggiore di Lodi, Lodi, Italy; 4Department of Pediatrics, University of Brescia, Spedali Civili, Brescia, Italy; 5Department of Pediatrics IRCCS Policlinico San Matteo Foundation-University of Pavia; 6IRCCS San Raffaele Hospital, Università Vita-Salute San Raffaele, Milano
Abstract: SARS-CoV-2 infection commonly presents with mild to severe respiratory symptoms and possibly other organs involvement. Gastrointestinal manifestations have been frequently documented in adult patients whilst their occurrence in children is uncertain. This study aimed to perform a Systematic Review of gastrointestinal symptoms in children with Coronavirus disease (COVID-19) and to compare these clinical findings with those reported in a cohort of Italian children in the early phase of pandemic.
Methods: Literature search was conducted using the Cochrane Library and MEDLINE (via Pubmed) databases from 1st December 2019 to 28th April 2020, according to the PRISMA guidelines. The following search terms were inserted: “Coronavirus” OR “COVID-19” OR “SARS-CoV-2” AND “gastrointestinal” or “diarrhea”. Only papers including children (0-18 years) and gastrointestinal symptoms were considered as eligible. Data records of children living in Lombardy, Italy, with infection of SARS-CoV-2 diagnosed by rRT-PCR on pharyngeal swabs, from 1st March to 28th April were also collected, analyzed and compared.
Results: The Systematic Review showed that only a minority of studies assessed gastrointestinal symptoms in children. However, diarrhea accounted for 0-50%, vomit 5-67% and abdominal pain 5.8-33.3% of infected children and gastrointestinal symptoms may represent the sole feature of COVID-19. Gastrointestinal symptoms were reported in 51/116 (44%) Italian children with SARS-CoV-2 infection. Poor feeding was present in 23.3% of children, diarrhea (median duration 2.3 days, range 1-5 days) in 22.4%, vomit in 10.4% and abdominal pain in 6.9% of cases. Respiratory symptoms were reported in 35.3% of children with gastrointestinal symptoms that represented the first clinical manifestation of COVID-19 in 25% of all patients.
Conclusions: We found that gastrointestinal symptoms are common in children with COVID-19 and, in some cases, they may represent the first and the sole clinical manifestation of SARS-CoV-2 infection. Health care professionals must be aware of the frequent gastrointestinal involvement in children to assure an accurate diagnosis and therapeutic management. The correct identification of children with COVID-19 is also crucial to adopt preventive measures and to limit the transmission of the virus.
Keywords: SARS-CoV-2, COVID-19, Coronavirus, Gastrointestinal, Diarrhea, Vomit, Abdominal pain, Poor feeding, Children.