Prevention of COVID-19 in children and neonates: A review

Author(s): Kourosh Rajabkhah, Moslem Taheri Soodejani, Marzieh Mahmudimanesh, Leili Abedi Gheshlaghi and Seyyed Mohammad Tabatabaei* Background: The novel coronavirus, called COVID-19, first originated in China and spread to many other countries. Due to the weakness of their immune system, especially in lower ages (infants) and also to prevent and control infection in this age group, special measures should be considered to prevent their infection with SARS-COV-2. The aim of this study is to invest ... Abstract View Full Article View DOI: 10.17352/apm.000015

Currently, the knowledge about this novel virus is limited but developing. Until the best treatment or vaccine is discovered to immunize the population, the best way is to prevent the disease in order manage it [9].
The COVID-19 prevention guideline, published by the WHO on February 27, 2020, provides solutions to prevent the disease; In addition, the way of disease transmission is determined by close contact and drops. The most effective preventive measures recommended in the community include: commonly hand wash and disinfection; preventing hands from touching eyes, nose and mouth; using napkin or elbow while sneezing or coughing; using a medical mask especially when there is respiratory symptoms considering a safely disposal, as well as keep social distancing from the one with symptoms (at least one meter). Similar recommendations are also provided for health care staffs [10]. On March 19, 2020, WHO published an interim guideline specifi cally for health care workers to prevent COV-19, which includes fi ve sections including: 1-Ensuring triage, early recognition, and source control (isolation of suspected cases); 2-Applying standard precautions for all patients; 3-Implementing empiric additional precautions (Droplets and contact, and whenever necessary, precautions in the air); 4-Implementing administrative controls; 5-Using environmental and engineering controls.
Numerous studies have also addressed the issue of disease prevention in different places including prevention strategies in hospital departments, such as hemodialysis and intensive care units [12,13], prevention in dental and ophthalmology offi ces [14,15] and prevention during pregnancy [16].
Naturally, children would also be affected during the outbreak. Due to the weakness of their immune system, especially in lower ages (infants) and also to prevent and control infection in this age group, special measures should be considered to prevent their infection with SARS-COV-2 (17). To the best of our knowledge, these has not been conducted a review on the prevention of COVID-19 among children, so, the aim of this study is to investigate the published evidences and provide a strategy for that matter.

Search strategy
Databases and e-journals including PubMed, Elsevier, Springer, Cambridge, Nature, Oxford, Google Scholar, Lancet, Cell, CDC, Nejm, JAMA, and BMC were searched using keywords derived from Mesh and get accessed until April 4, 2020. The search strategy was as follows: prevention AND ("COVID-19" OR Coronavirus OR "Corona virus" OR "2019-nCoV" OR "SARS-CoV" OR "MERS-CoV" OR "Severe Acute Respiratory Syndrome" OR "Middle East Respiratory Syndrome"). Searching of databases was performed independently by 4 people (MT, MM, KR and LA) and the fi nal articles were reviewed by one of the authors (MT).

Inclusion criteria
The original which reported the prevention of COVID-19 in children aged below 5 years, were included in the study. Review articles and the articles with incomplete data were excluded from the study. Also, studies on the prevention of COVID-19 in children older than 5, and at-risk groups including pregnant women and dialysis patients, were also excluded. The articles obtained from the databases were imported into the Endnote. After removing the duplications, also known as de-duplication, in the fi rst stage, their titles and abstracts were reviewed by two authors. Then, after adapting them to the research question, in the next stage, the full text of the articles was reviewed.
To reduce the chances of missing any article in the fi eld of COVID-19 prevention in children, the references of each were investigated and related one were selected. Finally, unrelated articles were removed.

Data extraction
The key data were extracted from the articles through a researcher-made checklist which included the fi rst author's last name, country and place of study, year of publication, type of study, target population, and actions taken. Data were extracted by all of the authors.

Results
After reviewing 159 published articles on COVID-19 prevention, 5 articles which was related to prevention in children were fi nally selected ( Figure 1).
The articles provided various recommendations for children, the most important of which were the encouragement of keeping on their routine vaccination under the immunization program, breast deeding, isolating them, and helping them to develop their personal hygiene. Routine care for infants and children, as well as proper nutrition them to help their immune systems, are other recommendations that have been highlighted in order to prevent from the disease. In these studies, it is strongly suggested that nurses and pediatricians at hospitals use protective equipment such as hats and glasses. On the other hand, the general advices given to other people were also emphasized for children; advices such as isolation, quarantine, social distancing, and prevention of close contact with people are suspected to be infected with SARS-COV-2 are other measures that should be considered to prevent this disease in children. More details can be found in Table 1.

Discussion
Among the fi ve studies found, there three studies were about prevention in infants [17][18][19][20] and two were about prevention in Two studies out of three which were about prevention in infants, investigated breastfeeding [17,19]. These studies emphasized that there is a possibility of vertical transmission through breast milk from an infected mother to her child and caution should be considered in this regard. In other viruses, such as Rhinovirus, there was no relationship between breast milk and the prevalence of the disease in infants [25]. Also, the results of a case study about SARS virus improved that the antibodies of this virus do exist in breast milk [26]. Recent studies about the possibility of transmitting COVID-19 through breast milk have acknowledged that further studies are needed to be determined [27].

Zimmermann and Lu have suggested hand hygiene and hand washing to prevent infants and children from COVID-19
in their study [18,20]. In a study by Koul, et  mask, and the importance of hand hygiene were emphasized [29]. In a study by Sikkema, et al. In order to prevent people who are at high risk places from getting infected with MERS-CoV, proper hand hygiene had identifi ed as an effective factor [30]. Other similar studies have suggested washing hands to prevent coronavirus transmission (MERS-CoV and SARS-CoV) in different populations, including controlling SARS infection in a hospital, prevention of infection in medical students who deal with patients infected with SARS-COV at hospital, as well as staffs working at health centers which deal with travelers arriving from high-risk areas and places with high prevalence of MERS-CoV and SARS-CoV [31][32][33][34][35].
Among the studies found, there were two about the effects of environmental disinfection to prevent disease in children and infants [19,21]. This has also been addressed in the case  [38]. The use of povidone-iodine products (PVP-I) as well as using high temperatures were other methods used to kill SARS-COV in two studies by Kariwa and Rabenau [39,40].
A number of studies have also suggested supportive care and stress management to help protect children from COVID-19 [17,21]. The use of appropriate supportive care, such as maintaining fl uid and electrolyte balance in the body and providing adequate oxygenation for SARS-COV prevention, was emphasized in the study of Hui, et al. [41]. Also the results of two studies by Park and Kim in which nurses working at a hospital during the MERS epidemic were investigated, and given that the prevalence of an epidemic has negative effects on mental health, showed that an educational / intervention program that covers all aspects of work hardship and stress might be a preventative measure [42,43]. Records screened (n =156) Records excluded, due to irrelevancy (after checking the tittle and abstract) (n =151)

Conclusion
Full-text articles assessed for eligibility (n = 5) Articles were included for assessing (n =5)

Funding
This research did not receive any specifi c grant from funding agencies in the public, commercial, or not-for-profi t sectors.