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Clinico-Epidemiological Characteristics of Pediatric COVID-19 Patients in Bangladesh

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Background To delineate the clinico-epidemiological characteristics of pediatric coronavirus disease-2019 (COVID-19) patients was the objective of the study. Method This observational study included 290 pediatric patients with a definite diagnosis of COVID-19 admitted to Dhaka Shishu Hospital, Bangladesh, from April 2021 to October 2021. Clinical and epidemiological characteristics were analyzed based on demographic data, medical history, laboratory tests, and outcome information. Data analysis was performed with SPSS 26. Ethical measures were taken in compliance with the current declaration of Helsinki, and final analysis was performed using SPSS 26. Result Of all, 42 (14.5%) were neonates (< 28 days), 88 (30.3%) were infants (28 days to < 1 year) and 160 (55.2%) were children (1–17 years). The median age of the children was 18 (0.3–204) months, 58.3% were male, 62% had malnutrition, and presented with various clinical presentations. The main symptoms were fever (5.7%) and breathlessness (20%). Approximately 22% of children were asymptomatic, and 57% had at least one comorbidity. Fever and abdominal pain were predominant presenting symptoms in children compared with neonates and infants (p < .01 for both), while cough and breathlessness were more frequent in infants (p < .01 for both). The infants suffered significantly from neutropenia and lymphocytosis than neonates and children (p < .001 for both). The discharge and death rates were 77.8% with 6.9%. Overall case fatality was higher among neonates than others. Conclusion Compared to other pediatric groups, neonatal case fatality was higher, and COVID-19 in neonates, infants, and children has similar epidemiological and clinical manifestations. The findings from this study might help to guide the development of measures to prevent and treat this ongoing global pandemic of these particular age groups.
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Clinico-Epidemiological Characteristics of Pediatric
COVID-19 Patients in Bangladesh
Probir Kumar Sarkar
Dhaka Shishu (Children) Hospital
Kinkar Ghosh
Dhaka Shishu (Children) Hospital
Dr Reaz Mobarak
Dhaka Shishu (Children) Hospital
Md Kamruzzaman
Dhaka Shishu (Children) Hospital
Rizwanul Ahsan
Dhaka shishu (Children) Hospital
Dr Shireen Afroz
Dhaka Shishu (Children) Hospital
Maksudur Rahman
Dhaka Shishu (Children) Hospital
Nabila Akand
Dhaka Shishu (Children) Hospital
Nahid Farzana
Dhaka Shishu (Children) Hospital
Shah Ali Akbar Ashra
Dhaka Shishu (Children) Hospital
Maleeha Sheefa
World Health Organization: Bangladesh Oce
Nurun Nahar
Dhaka Shishu (Children) Hospital
Dr Syed Sha Ahmed
Dhaka Shishu (Children) Hospital
Sheikh Wasik Rahman
Child Health Research Foundation
Anjim Macsud
Pi Research Consultancy Center
Mohammad Jahid Hasan ( )
Pi Research Consultancy Center
Research Article
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Keywords: Children, COVID-19, Pandemic, Neonate, Infants, Clinical manifestations
License: This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full
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To delineate the clinico-epidemiological characteristics of pediatric coronavirus disease-2019 (COVID-19)
patients was the objective of the study.
This observational study included 290 pediatric patients with a denite diagnosis of COVID-19 admitted to
Dhaka Shishu Hospital, Bangladesh, from April 2021 to October 2021. Clinical and epidemiological
characteristics were analyzed based on demographic data, medical history, laboratory tests, and outcome
information. Data analysis was performed with SPSS 26. Ethical measures were taken in compliance with the
current declaration of Helsinki, and nal analysis was performed using SPSS 26.
Of all, 42 (14.5%) were neonates (< 28 days), 88 (30.3%) were infants (28 days to < 1 year) and 160 (55.2%)
were children (1–17 years). The median age of the children was 18 (0.3–204) months, 58.3% were male, 62%
had malnutrition, and presented with various clinical presentations. The main symptoms were fever (5.7%) and
breathlessness (20%). Approximately 22% of children were asymptomatic, and 57% had at least one
comorbidity. Fever and abdominal pain were predominant presenting symptoms in children compared with
neonates and infants (p < .01 for both), while cough and breathlessness were more frequent in infants (p < .01
for both). The infants suffered signicantly from neutropenia and lymphocytosis than neonates and children
(p < .001 for both). The discharge and death rates were 77.8% with 6.9%. Overall case fatality was higher
among neonates than others.
Compared to other pediatric groups, neonatal case fatality was higher, and COVID-19 in neonates, infants, and
children has similar epidemiological and clinical manifestations. The ndings from this study might help to
guide the development of measures to prevent and treat this ongoing global pandemic of these particular age
1. Background:
Since December 2019, an outbreak of undiagnosed pneumonia cases with presumptive viral origin started in
Wuhan, China, and began to spread rapidly throughout the world [1]. At the beginning of 2020, the International
Committee on Taxonomy of Viruses denominated this new virus severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) [2]. The World Health Organization (WHO) designates this pandemic disease as coronavirus
disease 2019 (COVID-19) [2–4] and later declares a public health emergency of international concern [5]. To
date, over 140million patients have been diagnosed with COVID-19 globally [6]. The cumulative number of
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laboratory-conrmed cases has been reported to be over 700,000, and more than 10,000 reported deaths [7].
The clinical spectrum of COVID-19 is wide, varying from completely asymptomatic forms to those
characterized by severe respiratory distress requiring intensive care resulting in death [8–10]. All ages are
susceptible to this infection. However, the number of conrmed cases in children with COVID-19 is relatively
small; hence, very limited information is available compared to adults [11, 12]. One of the largest surveys
revealed that 2.2% [13] of children were affected in China, while in the USA, the number was 1.7% [14]. The
exact prevalence of COVID-19 among Bangladeshi children is still lacking.
Ample evidence suggests that compared to adults, children with COVID-19 have distinct epidemiological and
clinical manifestations [15]. For example, when adult patients predominantly present with fever, cough,
breathlessness, sore throat, and headache, children present with cough, pharyngitis, fever, diarrhea, vomiting,
and a negligible amount of gustatory and olfactory symptoms [16–18]. In addition, there are fewer severe
cases than adults [17, 19, 20]. Most likely, therefore, very limited comprehensive guidelines are available
focusing on the management of COVID-19 in children rather than adults [16]. However, understanding the
clinical manifestation of the pediatric population and their variation in different age groups, including neonates
(< 28 days), infants (28 days to < 1 year), and children (1 year to < 18 years), is important for clinical and
containment strategies. Considering the lack of detailed epidemiological information of pediatric patients, we
conducted an observational study to record epidemiological and clinical features and outcome data up to
discharge among the different pediatric populations (neonates, infants, and children < 18 years) admitted to
Dhaka Shishu Hospital, Bangladesh.
2. Methods;
2.1 Study design and participants:
This observational study was approved by the institutional review board (IRB) of Dhaka Shishu Hospital (DSH),
Dhaka, Bangladesh [ethical approval no. 651(1)/DSH/2020)]. Children admitted to the hospital with clinical
features consistent with COVID-19 were initially quarantined prior to SARS-CoV-2 nucleic acid detection [21].
Bed-sided nasopharyngeal swab of suspected patients was collected using a swab stick by a skilled health
care worker for RT-PCR. Suspected COVID-19 cases were dened as the presence of at least one clinical
manifestation: fever, breathlessness, tachypnea, lethargy, poor feeding, cough, vomiting, diarrhea, sore throat, or
runny nose during admission. A reverse transcriptase-polymerase chain reaction (RT-PCR) test was performed
for all suspected cases with the samples collected from the respiratory tract. Laboratory-conrmed [positive RT-
PCR (qualitative) for SARS-CoV-2] cases were nally included within the period spanning from May 2020 to
December 2020. Parents who did not provide consent to participate in the study refrained from inclusion.
Assessment of the children and management was ensured according to the recommendation of the National
Guidelines on Clinical Management of COVID-19 [22] and interim guidance provided by the Bangladesh
Pediatric Association (BPA). Details of the patient selection are available in supplementary Fig.1.
Data collection procedure:
A preformed questionnaire was prepared based on published literature and was piloted among 15 cases
admitted to DSH. Experiences from the piloting were adjusted during the nalization of the questionnaire. The
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medical records of the included patients were accessed by the study research physicians. Prior to data
collection, all of the research physicians (a total number of four) were trained for data collection and clinical
record assessment. Clinical data were extracted, including demographic data, clinical symptoms, signs,
comorbidities, and laboratory ndings. Nutritional assessments were also performed by a growth monitoring
promotion (GMP) card. Mid upper arm circumference (MUAC) tape was used during the assessment of mid
upper arm circumference (MUAC), and body weights of neonates and infants were measured with WS590 -
Baby Weighing Scales. For children aged more than 1 year, a digital body weight measuring scale was used. All
patients were managed by standard care for COVID-19. Comorbidities were also managed based on the
diagnosis and treatment protocol of the disease. All patients were followed-up to the discharge. The outcome
was dened as recovery, death, referred to the superspecialized center, and left the hospital against advice. The
discharge criteria followed in the study were as follows: normal body temperature or no fever for at least three
consecutive days; alleviation of upper respiratory symptoms (in comparison to the admission day); and
negative RT-PCR (qualitative) results obtained for SARS-CoV-2 nucleic acid detection at day 14 (from the index
test). Written informed consent was provided by their parents or guardians before data collection.
Quality assurance of the data and reporting guidelines
The principal investigator and/or his team supervised the data collection procedures and randomly cross-
checked the collected data to ensure quality control. In case of any breach of the standard procedure observed,
the investigator team communicated with the research physicians and attending doctors to maintain the
standard care and data collection process. After completion of the data collection, all data were sorted and
stratied into three groups based on the age difference. Here, neonates were considered age less than 28 days,
infants less than 1 year, and children between 1 year and < 18 years of age.
Statistical analyses:
Statistical analyses were conducted using SPSS software (version 26, IBM statistics). Missing values were
managed by subtracting the data from the nal data set. No mean imputation was made. Continuous data are
expressed as the mean ± standard deviation or median (range), while categorical data are presented as a
number, frequency, or percentage. Both parametric and nonparametric tests were used whenever necessary. The
results are expressed with 95% condence intervals (CIs), and a p-value < .05 was considered statistically
3. Results:
A total of 290 pediatric patients with COVID-19 were included in the study. The median age of the patients was
18 months, with a range between 1 day and 17 years. Of all, 42 (14.5%) were neonates, 88 (30.3%) were infants
and 160 (55.2%) were children. More than half of the pediatric patients were male (58.3%). Among all 73
(45.3%), 26 (16.1%) and 1 (0.6%) had severe malnutrition, moderate malnutrition and overnutrition, respectively.
Nearly half of the pediatric patients (n = 146, 50.3%) had at least one comorbidity, and 20 (6.9%) had more than
one comorbidity. Single comorbidities were signicantly more common among children than neonates and
infants, while more than one comorbidity was signicantly more common among neonates (p < 0.001)
(Table1). A detailed list of comorbidities found among the pediatric patients is presented in supplementary
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table 1. Acute leukemia and nephrotic syndrome were the comorbidities found in a signicantly higher
proportion in children (p < 0.05).
Table 1
Demographic characteristics, nutritional status and comorbidities of pediatric patients with COVID-19 (n = 
Variable Total
n (%)
n (%)
n (%)
Number 290 42 (14.5) 88 (30.3) 160 (55.2)
Age (months)  
Median 18 (0.3–204) 0.25 (0.03–0.87) 6 (0.97-12.00) 64 (13–204)
Sex  
Male 169 (58.3) 27 (64.3) 53 (60.2) 89 (55.6) 0.542
Female 121 (41.7) 15 (35.7) 35 (39.8) 71 (44.4)
Weight (kg)  
Mean ± SD 7.61 ± 4.63 2.84 ± 0.49 5.73 ± 2.07 12.28 ± 3.67 
Nutritional Status*  
Normal 61 (37.9) 12 (35.3) 23 (33.3) 26 (44.8) 0.448
Severe malnutrition 73 (45.3) 17 (50.0) 36 (52.2) 20 (34.5)
Moderate malnutrition 26 (16.1) 5 (14.7) 10 (14.5) 11 (19.0)
Overnutrition 1 (0.6) 0 0 1 (1.7)
Number of comorbidities  
One 146 (50.3) 5 (11.9) 37 (42.0) 104 (65.0) < 0.001
More than one 20 (6.9) 1 (24) 7 (8.0) 12 (7.5)
None 124 (42.8) 36 (85.7) 44 (50.0) 44 (27.5)
value determined by Chi-square test
*Excluding 129 missing values
The common clinical presentation was fever (n = 150, 51.7%), followed by breathlessness (n = 58, 20.0%),
abdominal pain (n = 48, 16.6%), cough (n = 42, 14.5%), seizure (n = 37, 12.8%), and vomiting (n = 36, 12.4%),
among others. Fever, abdominal pain, vomiting, rash, and weakness were signicantly more common among
children (p < 0.05). Breathlessness, cough, seizure, and vomiting were signicantly more common among
infants (p < 0.05) (Table2).
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Table 2
Clinical presentation of pediatric patients with COVID-19 (n = 290)
Variable Total
n (%)
n (%)
n (%)
n (%)
(n = 290) (n = 42) (n = 88) (n = 160)
Asymptomatic 65 (22.4) 35 (83.3) 13 (14.8) 17 (10.6) < 0.001
Fever 150 (51.7) 5 (11.9) 47 (53.4) 98 (61.3) < 0.001
Breathlessness 58 (20.0) 4 (9.5) 33 (37.5) 21 (13.1) < 0.001
Abdominal pain 48 (16.6) 0 11 (12.5) 37 (23.1) 0.001
Cough 42 (14.5) 1 (2.4) 22 (25.0) 19 (11.9) 0.001
Seizure 37 (12.8) 3 (7.1) 15 (17.0) 19 (11.9) 0.268
Vomiting 36 (12.4) 0 9 (10.2) 27 (16.9) 0.009
Sepsis 17 (5.9) 5 (11.9) 7 (8.0) 5 (3.1) 0.059
Oedema 16 (5.5) 1 (2.4) 4 (4.5) 11 (6.9) 0.487
Loose motion 14 (4.8) 0 7 (8.0) 7 (4.4) 0.138
Rash 13 (4.5) 0 1 (1.1) 12 (7.5) 0.023
Seizure 12 (4.1) 0 5 (5.7) 7 (4.4) 0.321
Feeding problem 11 (3.8) 0 6 (6.8) 5 (3.1) 0.147
Weakness 9 (3.1) 0 0 9 (5.6) 0.021
Sore throat 3 (1.0) 0 0 3 (1.9) 0.722
Runny nose 2 (0.7) 0 1 (1.1) 1 (0.6) 1.000
Unconsciousness 2 (0.7) 0 1 (1.1) 1 (0.6) 1.000
Delayed Cry 2 (0.7) 2 (4.8) 0 0 0.021
Local Swelling 1 (0.3) 0 0 1 (0.6) 1.000
value determined by Chi-square test
Table3 describes the investigation prole of the pediatric patients with COVID-19. The average hemoglobin
level was 10.95 ± 2.78 g/dl (SD), with a signicantly higher level among neonates than infants and children (p < 
0.001). The average hematocrit was 34.54 ± 9.72% (SD), with a signicantly higher value in neonates than in
infants and children (p < 0.001). The median WBC count was 11.20 x 103/mm3, ranging from 0.01 to 127.80 x
103/mm3, with children having a signicantly lower WBC count than neonates and infants (p < 0.001). The
percentage of neutrophils was signicantly lower and lymphocytes was signicantly higher among infants
than among neonates and children (p < 0.001). The median platelet count among pediatric patients was 2.80 x
106/mm3, with a signicantly higher median value among infants than neonates and children (p < 0.001).
Serum creatinine was signicantly higher among neonates than among infants and children (p = 0.002).
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Table 3
Investigation prole of pediatric patients with COVID-19 (n = 290)
Investigation Total
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Hemoglobin (g/dl) 10.95 ± 2.78 14.64 ± 3.02 10.46 ± 1.75* 10.28 ± 2.45* < 
Hematocrit (%) 34.54 ± 9.72 46.71 ± 10.10 33.43 ± 6.77* 32.07 ± 8.69* < 
RBC (x 106/mm3)4.23 ± 0.95 4.42 ± 0.90 4.19 ± 0.77 4.04 ± 1.03 0.087
WBC (x 103 /mm3)11.20 (0.01–
127.80) 12.50 (3.80–
37.10) 12.30 (0.01–
126.00) 10.10 (1.10–
Neutrophil (%) 53.00 (3.00–
91.00) 59.00 (17.00–
89.00) 38 (9.00–
85.00)* 54.50 (3.00–
Lymphocyte (%) 41.00 (6.00–
95.00) 31 (6.00–
72.00) 51.50 (10.00–
84.00)* 38.50 (7.00–
Monocyte (%) 5.00 (0–34.00) 6 (0–13.00) 6 (0–12.00) 4.00 (0–34.00)!0.004
Eosinophil (%) 1.00 (0–17.00) 1.00 (0–7.00) 1.00 (0–17.00) 1.00 (0–16.00) 0.933
Platelet (x
2.80 (0.12–
8.06) 2.52 (0.24–
6.76) 3.70 (0.22–
8.06)* 2.57 (0.12–
Serum creatinine
(mg/dl) 0.49 (0.01–
10.71) 0.84 (0.33–
5.11) 0.42 (0.01–
5.72)* 0.50 (0.03–
10.71)* 0.002
Sodium (mmol/l) 141.38 ± 5.59 142.56 ± 6.49 140.88 ± 5.11 141.279 ± 5.53 0.371
(mmol/l) 4.52 ± 1.04 5.28 ± 1.29 4.83 ± 0.97 4.13 ± 0.77*!< 
Chloride (mmol/l) 102.29 ± 12.25 101.73 ± 14.37 103.76 ± 8.29 101.70 ± 13.28 0.571
Data is expressed as mean ± SD or median (min-max).
P-value determined by ANOVA and Kruskal Wallis Test where appropriate. Post-hoc analysis was conducted
using Bonferroni or Games-Howell test. p < 0.05 in relation to Neonate* and Infant!
Among 290 pediatric children, outcome data were available for 288. Out of 288 pediatric participants, 78%
recovered, 11% were referred, 7% died and 4% left against advice (Fig.1).
We compared the demographic, nutritional, comorbidity, and investigation proles between pediatric patients
with COVID-19 who died and those who recovered (Table4). The number of deaths was signicantly higher
among neonates than among infants and children (p < 0.05). Death did not vary signicantly with the sex,
nutritional status, or comorbidity of the patients. On investigation, hemoglobin, WBC count, neutrophil
percentage, serum creatinine, and serum potassium level were signicantly higher among those who died than
among those who recovered (p < 0.05). However, lymphocyte and monocyte percentages were signicantly
lower among patients who died than among those who recovered (p < 0.05).
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Table 4
Outcome of pediatric patients with COVID-19 in relation different characteristics (n = 290)
Variable Dead Recovered p-value
n (%) 20 (8.2) 224 (91.8)
Age, n (%)   
Neonate 8 (19.5) 33 (80.5) 0.023*
Infant 5 (7.0) 66 (93.0)
Children 7 (5.3) 125 (94.7)
Sex, n (%)  
Male 12 (8.3) 132 (91.7) 0.926*
Female 8 (8.0) 92 (92.0)
Nutritional Status, n (%)   
Normal 1 (2.0) 49 (98.0) 0.247*
Severe malnutrition 6 (9.7) 56 (90.3)
Moderate malnutrition 1 (4.3) 22 (95.7)
Overnutrition 0 1 (100.0)
Number of comorbidities, n (%)  
One 7 (5.7) 115 (94.3) 0.176*
More than one 3 (16.7) 15 (83.3)
None 10 (9.6) 94 (90.4)
Investigation   
Hemoglobin (g/dl) 13.04 ± 4.02 10.93 ± 2.53 0.049***
Hematocrit (%) 41.43 ± 13.56 34.65 ± 8.81 0.059***
RBC (x 106/mm3)4.19 ± 0.92 4.18 ± 0.90 0.945***
WBC (x 103 /mm3)14.50 (1.10–37.10) 10.80 (0.01–127.80) 0.014
Neutrophil (%) 61.00 (41.00–89.00) 52.50 (3.00–89.00) 0.008
Lymphocyte (%) 30.00 (6.00–54.00) 41.00 (6.00–94.00) 0.012
Monocyte (%) 4.00 (0–11.00) 5.00 (1.00–25.00) 0.028
Eosinophil (%) 0 (0–6.00) 1.00 (0–16.00) 0.256
value determined by *Chi-square test, Fisher’s Exact test, ***Independent samples t test and Mann-
Whitney U test where appropriate
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Variable Dead Recovered p-value
Platelet (x 106/mm3)2.55 (0.24–5.78) 2.84 (0.12–7.76) 0.374
Serum creatinine (mg/dl) 0.70 (0.45–2.27) 0.47 (0.03–5.72) 0.011
Sodium (mmol/l) 142.47 ± 5.53 141.27 ± 5.58 0.402***
Potassium (mmol/l) 5.40 ± 0.90 4.41 ± 1.02 < 0.001***
Chloride (mmol/l) 104.44 ± 6.07 101.84 ± 13.52 0.436***
value determined by *Chi-square test, Fisher’s Exact test, ***Independent samples t test and Mann-
Whitney U test where appropriate
COVID-19 can affect any age. However, globally, the frequency and case fatality of COVID-19 is comparatively
low in the pediatric group[23]. Although several studies reported exclusively on children, a few studies
compared the demographic and clinical features across different age ranges[24, 25]. Our study presents a
comparative analysis of patient characteristics in neonates, infants, and children in the pediatric age group. We
also explored the factors affecting death among pediatric patients with COVID-19.
The median age of our participants was 18 months (1.5 years), and we obtained COVID-19-affected neonates
aged as low as one day and children as high as 17 years. Nearly half of the participants were aged less than
one year, which is higher than that found by Anwar
et al.
[26]. The median age of pediatric patients with COVID-
19 varies from study to study based on the target population and method of selection. A systematic review on
the pediatric group by Patel [24] found that the reported median age ranges from 1 to 11 years. The author also
presents a composite mean age of 7.9 years with an age range between 1 day and 17 years, similar to our
study. These ndings demonstrate the SARS-CoV-2 virus's ability to infect anyone and children most likely got
the virus from their infected parents or family members. This assumption is supported by studies among
neonates which showed that half of the patients had infections from their infected mother, and one-third were
admitted to the hospital [27].
Males were more common than females in our study, which corresponds to the ndings of other studies [24].
We found this true for all age range. The higher anity of SARS CoV-2 towards males than females might be
explained by the fact that angiotensin-converting enzyme 2 (ACE2), the receptor for the virus, is expressed more
in the former sex than in the latter along with other sex-based immunological and hormonal differences [28].
We found that more than 60 percent of pediatric patients had malnutrition irrespective of age group. This
nding is important, as nutrition shows a reciprocal relationship with infection, and good nutritional status is
associated with good immune function [29]. Additionally, more than half of them had at least one comorbidity,
with the frequency being signicantly higher among children and infants than among neonates. However, the
overall proportion of comorbidities found in our study was higher than that found in other studies [24] and
lower than that in those who needed neonatal intensive care unit admission[30]. Most of the comorbidities were
probably coincident or concomitant ndings in COVID-19 rather than precipitating factors. As the virus spreads
via airborne respiratory droplets and mostly causes mild or asymptomatic disease in the pediatric population,
Page 11/16
in most cases, it was a coincidental nding in children presenting with other diseases in the hospital. However,
some of the diseases might be consequent of COVID
-19 as well. We noted multisystem inammatory syndrome in 3 children, which was previously established as a
rare but severe complication of COVID-19 among children[31].
Fever was the most common presentation, followed by breathlessness, abdominal pain, cough, seizure, and
vomiting, among others. Two previous studies conducted among children with COVID-19 in Bangladesh[26, 32]
also noted fever, cough, breathlessness, abdominal pain, and vomiting among the most common presenting
features. In a systematic review of individual participant data, Christopher
et el
[33] reported similar patterns of
presentation. However, the proportion of individual symptoms varied among studies. SARS CoV-2 binds with
ACE2, which is ubiquitous in the human body with high expression in the lungs, heart, ileum, kidney, and
bladder[34]. Hence, despite its entry through the lung, it might produce symptoms involving multiple systems of
the body. However, respiratory and gastrointestinal intestinal intestinal presentation is the most common mode
of presentation of the disease. We found that neonates were relatively asymptomatic compared to infants and
children. Gastrointestinal complaints such as abdominal pain and vomiting were more common among
children, and respiratory complaints such as breathlessness and cough were more common among infants.
et el
[33] noted that children less than 7 years old tended to present with gastrointestinal complaints
compared to older children. Our ndings also conform to their results, as most of the child participants in our
study were young with a median age of 64 months (5.33 years).
On laboratory investigations, we noted that children had signicantly lower WBC counts than neonates and
infants, with infants having signicantly lower neutrophils and higher lymphocyte counts than children.
However, laboratory data varied across pediatric participants based on the presence of various comorbidities
and were mostly within the normal range for the participants. Similarly, Patel noted that the test results
presented in various studies of COVID-19 children were mostly within the reference range used for that
particular study[24]. Interestingly, this is contrary to expected lymphopenia, and an elevated neutrophil-to-
lymphocyte ratio has emerged as a characteristic feature of severe COVID-19 [35], probably because of the
predominantly milder form of the disease in children.
Out of 288 participants for whom the outcome was known, 20 (6.9%) pediatric patients with COVID-19 died.
However, the case-fatality rate increased to 8.2% when referred patients were excluded. We found that age was
associated with death in pediatric patients with COVID-19, while sex, nutritional status, and the presence of
comorbidities did not show any association. The proportion of deaths was signicantly higher among neonates
than among infants and children. This rate is higher than that found by Ghosh et al[32] (1.4%) and Anwar et
al[26] (4.1%). The low number of neonates among their studies might explain the difference. However,
et al
[27] found zero case fatalities among 44 newborns with COVID-19. The provision of a well-
equipped and adequate number of neonatal intensive care units (NICUs) is an important requirement for the
appropriate management of these groups of patients. However, this is often not possible in developing
countries because of a lack of adequate treatment facilities. This could explain the high mortality among
neonates found in our study. Our analysis also revealed that certain investigation results were signicantly
different between dead and alive patients. However, this might have been inuenced by the higher number of
neonates dying instead of infants and children, as the physiology of neonates differs fundamentally from that
of older children.
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The current study was limited by the small sample size collected from a single center, lack of detection of
quantitative RT-PCR, radiological investigations, and dynamic detection of inammatory markers. However, our
study provided important insights into similarities and differences in characteristics, presentation, and outcome
of COVID-19 among neonates, infants, and children in the context of Bangladesh.
The study presents a detailed clinico-epidemiological pattern of COVID-19 among neonates, infants, and
children. About one-third of the patients remain asymptomatic. Fever and abdominal pain were the most
prominent manifestations among symptomatic patients. Slight variation in the symptoms and laboratory
investigations exists. In comparison to others, neonates are more vulnerable than other pediatric groups.
Competing interest statement:The author declares no competing interest.
Consent to participate:Informed written consent was ensured before participation of all subjects from the
accompanying parents.
Availability of data and material:Data and material are available from the corresponding authors and could be
shared based on reasonable request.
Author contributions:
The conception and design: PKS, KG, MK, AM, MJH
Data acquisition and data collection: SA, MR, NA, NF, SAAA, MS, NN, SSA, SWR
Data analysis was done by AM, MJH, and KG
Interpretation of the result: PKS, KG, MK, AM, MJH, SA, MR, NA, NF, SAAA, MS, NN, SSA, SWR
Project administration: PKS, KG, SA, MR, NA, NF, SAAA, MS, NN, SSA, SWR
First draft of the manuscript: PKS, KG, MK, AM, MJH and NA
Review of the draft: PKS, KG, MK, AM, MJH, SA, MR, NA, NF, SAAA, MS, NN, SSA, SWR
Final approval: PKS, KG, and MJH
The investigator team acknowledged the Department of Epidemiology & Research, Dhaka Shishu (Children)
Hospital for their constant support for data collection and data analysis, Child Health Research Foundation,
Page 13/16
Bangladesh for RT-PCR testing, and ‘Pi
Research Consultancy Center’ (
Bangladesh for their
cordial support for manuscript formatting and journal selection.
1. Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl
J Med. 2020 Feb 20;382(8):727–33. Available from:
2. ICTV. International Committee on Taxonomy Viruses Naming the 2019 Coronavirus. 2020 [cited 2020 Oct
11]. Available from:
3. Kandel N, Chungong S, Omaar A, Xing J. Health security capacities in the context of COVID-19 outbreak: an
analysis of International Health Regulations annual report data from 182 countries. Lancet (London,
England). 2020;395(10229):1047–53.
4. Amanat F, Krammer F. SARS-CoV-2 vaccines: status report. Immunity. 2020;52(4):583–9.
5. Barrero-Castillero A, Beam KS, Bernardini LB, et al. COVID-19: neonatal–perinatal perspectives. J Perinatol.
. WHO. Coronavirus disease (COVID-19) pandemic. 2021. Available from:
7. WHO. Coronavirus disease (COVID-19) update. 2021. Available from:
. Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020
Apr 30;382(18):1708–20. Available from:
9. Wong CKH, Wong JYH, Tang EHM, et al. Clinical presentations, laboratory and radiological ndings, and
treatments for 11,028 COVID-19 patients: a systematic review and meta-analysis. Sci Rep. 2020;10(1):1–
10. Hasan MJ, Tabssum T, Ambia NE, et al. Mental Health of the COVID-19 Patients in Bangladesh.
Mymensingh Med J. 2021 Jan;30(1):189–95. Available from:
11. Ma H, Hu J, Tian J, et al. A single-center, retrospective study of COVID-19 features in children: a descriptive
investigation. BMC Med. 2020 Dec 6;18(1):123. Available from:
12. Wei M, Yuan J, Liu Y, et al. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in
China. JAMA. 2020;13(323):1313. Available from:
13. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019
(COVID-19) Outbreak in China. JAMA. 2020 Apr 7;323(13):1239. Available from:
14. CDC COVID-19 Response Team. Coronavirus disease 2019 in children—United States, February 12-April 2,
2020. MMWR Morb Mortal Wkly Rep. 2020;2020(69):422–6.
15. Guo CX, He L, Yin JY, et al. Epidemiological and clinical features of pediatric COVID-19. BMC Med.
Page 14/16
1. Li B, Zhang S, Zhang R, et al. Epidemiological and Clinical Characteristics of COVID-19 in Children: A
Systematic Review and Meta-Analysis. Front Pediatr. 2020;8(November):1–12.
17. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. N Engl J Med. 2020 Apr 23;382(17):1663–5.
Available from:
1. Viner RM, Ward JL, Hudson LD, et al. Systematic review of reviews of symptoms and signs of COVID-19 in
children and adolescents. Arch Dis Child. 2020 Dec 17;archdischild-2020-320972. Available from:
19. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than
adults. Acta Paediatr Int J Paediatr. 2020;109(6):1088–95.
20. Castagnoli R, Votto M, Licari A, et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
Infection in Children and Adolescents. JAMA Pediatr. 2020 Sep 1;174(9):882. Available from:
21. WHO. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV)
infection is suspected. 2020 [cited 2021 Apr 17]. Available from: publications-
detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus- (ncov)-infection-
22. Foundation TI. Guidelines on clinical management of Thalassaemia. 2008;(November). Available from:
23. Age, Sex, Existing Conditions of COVID-19 Cases and Deaths. 2021.
24. Patel S. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in
English and Mandarin on the novel coronavirus COVID- 19 . The COVID-19 resource centre is hosted on
Elsevier Connect , the company ’ s public news and information. Gene Reports. 2017;7(January):127–41.
25. Soares G, Barros G, Cordeiro KR, et al.. Epidemiological characteristics of COVID-19 in pediatric patients
under 10 years old : a systematic review Características epidemiológicas da COVID-19 em pacientes
pediátricos menores de 10 anos : uma revisão sistemática. 2021;1(Suppl 2):39–40.
2. Anwar S, Shamsad IA, Morshed AKMA, et al. Clinical Prole of Child COVID-19 Patients of Bangladesh.
2021;7(March 2020):5–8.
27. Trevisanuto D, Cavallin F, Cavicchiolo ME, et al. Coronavirus infection in neonates: A systematic review.
Arch Dis Child Fetal Neonatal Ed. 2020;1–6.
2. Bwire GM. Coronavirus: Why Men are More Vulnerable to Covid-19 Than Women? SN Compr Clin Med.
29. Scrimshaw NS, SanGiovanni JP. Synergism of nutrition, infection, and immunity: An overview. Am J Clin
Nutr. 1997;66(2).
30. Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with
coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units.
JAMA Pediatr. 2020;174(9):868–73.
31. Consiglio CR, Cotugno N, Sardh F, et al. The Immunology of Multisystem Inammatory Syndrome in
Children with COVID-19. Cell. 2020;183(4):968-981.e7. Available from:
Page 15/16
32. Ghosh UK, Sultana A, Ghosh NK, et al. Clinico-demographic Prole of Coronavirus Infection among
Bangladeshi Children: A Tertiary Care Hospital Study. Bangladesh J Infect Dis. 2020;7(October):S16–21.
33. Christophers B, Marin BG, Oliva R, et al. Trends in clinical presentation of children with COVID-19: a
systematic review of individual participant data. Pediatr Res. 2020;(July). Available from:
34. Yuki K, Fujiogi M, Koutsogiannaki S, et al. Since January 2020 Elsevier has created a COVID-19 resource
centre with free information in English and Mandarin on the novel coronavirus COVID- 19 . The COVID-19
resource centre is hosted on Elsevier Connect , the company ’ s public news and information . 2020;
35. Reusch N, De Domenico E, Bonaguro L, et al. Neutrophils in COVID-19. Front Immunol.
2021;12(March):652470. Available from:
Figure 1
Outcome of pediatric patients with COVID-19 (n=288)
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Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
The mental health aspect of coronavirus disease-19 (COVID-19) patients in Bangladesh has remained less focused and has not been addressed properly. The objective of the study was to assess the levels of anxiety and depression in COVID-19 patients. We adopted a mixed online and telephone-based survey using Google Forms. Recruitment was performed through a snowball sampling approach. The Google Form was initially circulated in Facebook to identify interested participants. Then, three trained physicians interviewed the online responders over telephone for a period spanning from April 2020 to June 2020. Two well-known questionnaires, the Generalized Anxiety Disorder 7-item (GAD-7) scale and the Patient Health Questionnaire (PHQ-9), were used for the assessment of anxiety and depression, respectively. Here, the severity of anxiety was classified with the standard thresholds: minimal or none (0-4), mild (5-9), moderate (10-14) and severe (>15) for the GAD-7. Depression severity score: 0-4 was considered as none or no depression, 5-9: mild, 10-14: moderate, 15-19: moderately severe, 20-27 was for severe depression. A total of 237 patients were finally analyzed. The mean age ±SD of the patients was 41.59±13.73 years. Most of them were male (73%) and lived in urban areas (90.29%). Half of the patients were unemployed, and 17.7% admitted loss of job due to lockdown. The overall prevalence of anxiety and depression was 55.7% and 87.3%, respectively. The mean GAD-7 score was 5.79±4.95, and the mean PHQ-9 score was 5.64±5.15. Among the depressive patients, 3% had minimal depression, 38.4% had mild depression, 32.1% had moderate depression, 11.8% had moderate depression, and 2.1% had a severe depression. Similarly, 37.1%, 10.5% and 8% had mild, moderate and severe levels of anxiety, respectively. Nearly half of the study population (47.7%) was suffering from both depression and anxiety. Living in urban area was an independent predictor for depression (OR 3.882; CI: 1.249-12.069). Considering the high comorbid burden, the mental health issues of these patients need to be addressed and reinforced to the existing health system on a priority basis.
Full-text available
Given the relatively low rate and limited publicly available data regarding children with SARS-CoV-2 infection, this knowledge gap should be addressed with urgency. This systematic review with meta-analysis aimed to evaluate the epidemiological spectrum and clinical characteristics of children infected with SARS-CoV-2. Relevant international and Chinese public databases were systematically searched to identify all case studies from January 1, 2020 to May 7, 2020. This study consisted of 96 studies involving 7004 cases. The mean age of pediatric cases was 6.48 years (95% CI 52.0–77.5), 90% had household contact, and 66% presented with mild to moderate clinical syndromes. The main symptoms were fever (47%, 95% CI 41–53%) and cough (42%, 95% CI 36–48%). About 23% of children were asymptomatic, 27% had comorbidity, and 29% had a co-infection. The pooled mean incubation period was 9.57 days (95% CI 7.70–11.44). The shedding of SARS-CoV-2 in the upper respiratory tract lasted 11.43 days, and 75% of patients had virus particles in their stool. A total of 34% of the children had neutropenia and 26% had lymphocytosis. Interferon-alpha (81%) was the most commonly used antiviral drug in the children. The discharge and death rates were 79 and 1%. In conclusion, the transmissibility of pediatric COVID-19 should be not ignored because of the relatively long incubation period, shedding duration, and mild clinical syndromes.
Full-text available
Background: Variation and atypical presentation of COVID-19 in Bangladeshi children has been noticed. Objective: The purpose of the present study was to see the clinical and demographic features for easy and early identification of coronavirus infection. Methodology: This descriptive cross-sectional study was done at Dr. MR Khan Shishu Hospital & ICH, Dhaka, Bangladesh from April 2020 to August 2020. The suspected case of coronavirus infection was advised RT-PCR and symptomatic home treatment was given. Hospitalization was done in severe cases. Then diagnosis was made by clinical symptoms plus investigations and appropriate treatment was given. Then RT-PCR was done among them in suspected cases. Other investigations were done accordingly. Results: Among the 236 cases RT-PCR positive was found 71(30.08%) cases. The male-female ratio was 1.7:1. Mostly was 1 year to 2 years (21.13%) and 5 years to 10 years (21.13%). About twenty percent was asymptomatic, 80.28% was symptomatic, co-infections was 29.58%, and co-morbidities was 8.45%. The duration of RT-PCR was positive up to two, four, six, and more than six weeks 49.30%, 30.99%, 16.90%, and 2.82% respectively. Fever (80.28%), cough (45.07%), sore throat (33.80%), runny nose (29.58%), anorexia (28.17%), convulsion (25.35%), respiratory distress & acute diarrhea (15.50%), weakness (14.08%), paralytic ileus, rash and acute abdomen (4.23%). Conclusion: COVID-19 in Bangladeshi children are found with a variety of clinical presentations; unlike that of the adult. Bangladesh Journal of Infectious Diseases, October 2020;7(suppl_2):S16-S21
Full-text available
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is typically very mild and often asymptomatic in children. A complication is the rare multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, presenting 4-6 weeks after infection as high fever, organ dysfunction, and strongly elevated markers of inflammation. The pathogenesis is unclear but has overlapping features with Kawasaki disease suggestive of vasculitis and a likely autoimmune etiology. We apply systems-level analyses of blood immune cells, cytokines, and autoantibodies in healthy children, children with Kawasaki disease enrolled prior to COVID-19, children infected with SARS-CoV-2, and children presenting with MIS-C. We find that the inflammatory response in MIS-C differs from the cytokine storm of severe acute COVID-19, shares several features with Kawasaki disease, but also differs from this condition with respect to T cell subsets, interleukin (IL)-17A, and biomarkers associated with arterial damage. Finally, autoantibody profiling suggests multiple autoantibodies that could be involved in the pathogenesis of MIS-C.
Full-text available
There are sparse patient-level data available for children with novel coronavirus disease (COVID-19). Therefore, there is an urgent need for an updated systematic literature review that analyzes individual children rather than aggregated data in broad age groups. Six databases (MEDLINE, Scopus, Web of Science, CINAHL, Google Scholar, medRxiv) were searched for studies indexed from January 1 to May 15, 2020, with MeSH terms: children, pediatrics, COVID-19, SARS-CoV-2. 1241 records were identified, of which only unique papers in English with individual patient information and documented COVID-19 testing were included. This review of 22 eligible studies followed Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data guidelines. A total of 123 patients from five countries were identified. 46% were females. The median age was 5 years (IQR = 8). At presentation, 62% had a fever, 32% had a cough, 58% had a single symptom, and 21% were asymptomatic. Abnormal chest imaging was seen in 62% (65/105) of imaged and 76.9% (20/26) of asymptomatic children. A minority of children had elevated platelets, CRP, lactate dehydrogenase, and d-dimer. Data from this independent participant data systematic review revealed that the majority of children with COVID-19 presented with either no symptoms or a single, non-respiratory symptom. This systematic review revealed that the majority of children with COVID-19 presented with either no symptoms or a single, non-respiratory symptom. By using an independent participant data approach, this analysis underscores the challenge of diagnosing COVID-19 in pediatric patients due to the wide variety of symptoms and seemingly poor correlation of imaging findings with symptomatic disease. The data presented from individual patients from case series or cohort studies add more granularity to the current description of pediatric COVID-19.
Full-text available
Background: COVID-19 is an extremely severe infectious disease. However, few studies have focused on the epidemiological and clinical characteristics of pediatric COVID-19. This study conducted a retrospective review of the epidemiological and clinical features of COVID-19 in children. Methods: A retrospective study was conducted on children with a definite diagnosis of COVID-19 in mainland China using the web crawler technique to collect anonymous COVID-19 updates published by local health authorities. Results: Three hundred forty-one children aged 4 days to 14 years with a median age of 7 years were included. Sixty-six percent of pediatric patients were infected via family members with COVID-19. The median incubation period was 9 days (interquartile range, 6 to 13). Asymptomatic cases accounted for 5.9%, of which 30% had abnormal chest radiologic findings. A majority of pediatric COVID-19 cases showed mild to moderate clinical features, and only a few developed severe or critical diseases (0.6% and 0.3%, respectively). Fever (77.9%) and cough (32.4%) were the predominant presenting symptoms of pediatric COVID-19. The pediatric patients had fewer underlying diseases and complications than adults. The treatment modalities for pediatric COVID-19 patients were not as complex as those of adult COVID-19 patients. The overall prognosis of pediatric COVID-19 was benign with a decent recovery. The median time from onset to cure was 16 days (interquartile range, 13 to 21). Conclusions: Compared to adults, COVID-19 in children has distinct features of epidemiology and clinical manifestations. The findings from this study might help to guide the development of measures to prevent and treat this ongoing global pandemic. Trial registration: Chinese Clinical Trial Registry ( ) identifier: ChiCTR2000030464.
Full-text available
Amid of coronavirus disease 2019 (Covid-19) pandemic, much emphasis was initially placed on the elderly or those who have preexisting health conditions such as obesity, hypertension, and diabetes as being at high risk of contracting and/or dying of Covid-19. But it is now becoming clear that being male is also a factor. The epidemiological findings reported across different parts of the world indicated higher morbidity and mortality in males than females. While it is still too early to determine why the gender gap is emerging, this article point to several possible factors such as higher expression of angiotensin-converting enzyme-2 (ACE 2; receptors for coronavirus) in male than female, sex-based immunological differences driven by sex hormone and X chromosome. Furthermore, a large part of this difference in number of deaths is caused by gender behavior (lifestyle), i.e., higher levels of smoking and drinking among men compared to women. Lastly, studies reported that women had more responsible attitude toward the Covid-19 pandemic than men. Irresponsible attitude among men reversibly affect their undertaking of preventive measures such as frequent handwashing, wearing of face mask, and stay at home orders.
Objective To undertake a systematic review of reviews of the prevalence of symptoms and signs of COVID-19 in those aged under 20 years. Design Narrative systematic review of reviews. PubMed, medRxiv, Europe PMC and COVID-19 Living Evidence Database were searched on 9 October 2020. Setting All settings, including hospitalised and community settings. Patients Children and young people (CYP) under age 20 years with laboratory-proven COVID-19. Study review, data extraction and quality Potentially eligible articles were reviewed on title and abstract by one reviewer. Quality was assessed using the modified AMSTARS criteria and data were extracted from included studies by two reviewers. Main outcome measures Prevalence of symptoms and signs of COVID-19. Results 1325 studies were identified and 18 reviews were included. Eight were high quality, 7 medium and 3 low quality. All reviews were dominated by studies of hospitalised children. The proportion of asymptomatic CYP ranged from 14.6% to 42%. Fever and cough were the the most common symptoms; proportions with fever ranged from 46% to 64.2% and with cough from 32% to 55.9%. All other symptoms or signs including rhinorrhoea, sore throat, headache, fatigue/myalgia and gastrointestinal symptoms including diarrhoea and vomiting were infrequent, occurring in less than 10%–20%. Conclusions Fever and cough are the most common symptoms in CYP with COVID-19, with other symptoms infrequent. Further research on symptoms in community samples are needed to inform pragmatic identification and testing programmes for CYP.
The coronavirus disease 2019 (COVID-19) pandemic, resulting from infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused severe and widespread illness in adults, including pregnant women, while rarely infecting neonates. An incomplete understanding of disease pathogenesis and viral spread has resulted in evolving guidelines to reduce transmission from infected mothers to neonates. Fortunately, the risk of neonatal infection via perinatal/postnatal transmission is low when recommended precautions are followed. However, the psychosocial implications of these practices and racial/ethnic disparities highlighted by this pandemic must also be addressed when caring for mothers and their newborns. This review provides a comprehensive overview of neonatal–perinatal perspectives of COVID-19, ranging from the basic science of infection and recommendations for care of pregnant women and neonates to important psychosocial, ethical, and racial/ethnic topics emerging as a result of both the pandemic and the response of the healthcare community to the care of infected individuals.
Objective: To summarise currently reported neonatal cases of SARS-CoV-2 infection. Methods: A search strategy was designed to retrieve all articles published from 1 December 2019 to 12 May 2020, by combining the terms 'coronavirus' OR 'covid' OR 'SARS-CoV-2') AND ('neonat*' OR 'newborn') in the following electronic databases: MEDLINE/Pubmed, Scopus, Web of Science, MedRxiv, the Cochrane Database of Systematic Review and the WHO COVID-19 database, with no language restrictions. Quality of studies was evaluated by using a specific tool for assessment of case reports and/or case series. Results: Twenty-six observational studies (18 case reports and 8 case series) with 44 newborns with confirmed SARS-CoV-2 infection were included in the final analysis. Studies were mainly from China and Italy. Half of neonates had a documented contact with the infected mother and one out of three infected neonates was admitted from home. Median age at diagnosis was 5 days. One out of four neonates was asymptomatic, and the remaining showed mild symptoms typical of acute respiratory infections and/or gastrointestinal symptoms. The majority of neonates were left in spontaneous breathing (room air) and had good prognosis after a median duration of hospitalisation of 10 days. Conclusions: Most neonates with SARS-CoV-2 infection were asymptomatic or presented mild symptoms, generally were left in spontaneous breathing and had a good prognosis after median 10 days of hospitalisation. Large epidemiological and clinical cohort studies, as well as the implementation of collaborative networks, are needed to improve the understanding of the impact of SARS-CoV-2 infection in neonates.