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tomatic children resembled those in adults. Systematic measurements of SARS-CoV-2 viral load measurements in children are lacking. Therefore, transmission of SARS-CoV-2 from children is plausible (L’Huillier 2020). SARSCoV-2 in children is transmitted through family contacts and mainly through respiratory droplets (Garazzino 2020). In a study from France, child-to-child and child-to-adult transmission seems to be uncommon (Danis 2019). Prolonged exposure to high concentrations of aerosols may facilitate transmission (She 2020). SARS-CoV-2 may theoretically also be transmitted through the digestive tract. ACE2 is also found in upper esophageal and epithelial cells as well as intestinal epithelial cells in the ileum and colon (She 2020). SARS-CoV-2 RNA can be detected in the feces of patients (Holshue 2020). Cai revealed that viral RNA is detected from feces of children at a high rate (and can be excreted for as long as 2-4 weeks) (Cai 2020). However, direct evidence of a fecal-to-oral transmission has not yet been documented. Onward transmission from children to others is low (Viner 2020, Merckx 2020). In a study from Milan, Itlay, in 83 children and 131 adults hospitalized and symptomatic in regard to COVID-19, adults were retrospectively more likely to be CoV-2 positive, asymptomatic carriers as compared to children (9% vs 1%) (Milani 2020).
Diagnosis and classification Testing for the virus is only necessary in clinically suspect children. If the result is initially negative, repeat nasopharyngeal or throat swab testing of upper respiratory tract samples or testing of lower respiratory tract samples should be done. Sampling of the lower respiratory tract (induced sputum or bronchoalveolar lavage) is more sensitive (Han 2020). This is not always possible in critically ill patients and in young children. Diagnosis is usually made by real-time polymerase chain reaction RT-PCR on respiratory secretions. For SARS-CoV, MERS-CoV and SARS-CoV-2, higher viral loads have been detected in samples from lower respiratory tract compared with upper respiratory tract. In some patients, SARS-CoV-2 RNA is negative in respiratory samples while stool samples are still positive indicating that a viral gastrointestinal infection can last even after viral clearance in the respiratory tract. (Xiao 2020). Fecal testing may thus be of value in diagnosing COVID-19 in these patients. As in other viral infections, a CoV-2 IgM and IgG seroconversion will appear in days (IgM) to 1-3 weeks (IgG) after infection and may or may not indicate protective immunity (still to be determined). Interestingly, asymptomatic Kamps – Hoffmann
