Comment regarding pediatric severe acute respiratory syndrome coronavirus 2: clinical presentation, infectivity, and immune responses To the Editor: In the report by Yonker et al, despite having tested 11 asymptomatic children with 3 positives, there are no details about this group selection and there is no information about the viral load in this group. 1 It would be important to compare this group with the group study, instead of comparing asymptomatic/early infection with adults at a later stage of the disease. One study found a higher viral load in adults during the first week of symptoms with a pro- gressive decrease over time, as observed in the present study in children, reinforcing that comparing viral load at different stages of the disease may be inadequate. 2 Also, they correlated multisystem inflammatory syndrome in children with low viremia, and posed it as an obstacle to control strategies as re- opening schools. However, studies show that multisystem in- flammatory syndrome in children is a later complication, with a low incidence and mortality. 3,4 Data suggest that the majority of pediatric cases are mild or asymptomatic. 5,6 Therefore, we should ponder the impact of quarantine on childhood. There are psychological and phys- ical burdens imposed on children with home confinement and school closure: lack of children-children interaction and inadequate eating patterns generate distress, obesity/ malnutrition, depression, and many other behavioral and neurodevelopmental disorders. Additionally, vulnerable chil- dren like those exposed to domestic violence and abuse have no place to shelter. 7,8 Furthermore, in low-income countries, socioeducational disparity may be enhanced, because there is no universal access to audiovisual system or Internet access; in addition, some children receive vital nutritional assistance in schools that has been halted since the pandemic began. 7 Mitigating the psychosocial impact may require risk stratifi- cation of children, teachers, and their household contacts and contact tracing all symptomatic individuals making isolation possible. 9 The central question after their findings is if there is direct correlation between viral load and transmissibility. 10 Juliana Ferreira Ferranti, MD Pediatric Intensive Care Children’s Institute Faculty of Medicine University of Sao Paulo Pediatric Intensive Care Brazilian Israeli Beneficent Society Albert Einstein (SBIBAE) Sao Paulo, Brazil Natalia Viu Degaspare, MD Pediatric Intensive Care Children’s Institute Faculty of Medicine University of Sao Paulo Sao Paulo, Brazil Luciana Becker Mau, MD Emilio Ribas Institute of Infectology Sao Paulo, Brazil Artur Figueiredo Delgado, MD, PhD Werther Brunow de Carvalho, MD, PhD Pediatric Intensive Care Children’s Institute Faculty of Medicine University of Sao Paulo Sao Paulo, Brazil https://doi.org/10.1016/j.jpeds.2020.09.034 The authors declare no conflicts of interest. References 1. Yonker LM, Neilan AM, Bartsch Y, Patel AB, Regan J, Arya P, et al. Pediatric SARS-CoV-2: clinical presentation, infectivity, and immune responses. J Pediatr 2020. https://doi.org/10.1016/j.jpeds. 2020.08.037. 2. To KK-W, Tsang OT-Y, Leung W-S, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis 2020;20:565-74. 3. Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med 2020;383:334-46. 4. Dufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J, et al. Multisystem inflammatory syndrome in children in New York State. N Engl J Med 2020;383:347-58. 5. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. SARS-CoV-2 infection in children. N Engl J Med 2020;382:1663-5. 6. Lee B, Raszka WV Jr. COVID-19 Transmission and Children: the Child Is Not to Blame. Pediatrics 2020;146:e2020004879. 7. Ghosh R, Dubey MJ, Chatterjee S, Dubey S. Impact of COVID -19 on children: special focus on the psychosocial aspect. Minerva Pediatr 2020;72:226-35. 8. Wong CA, Ming D, Maslow G, Gifford EJ. Mitigating the impacts of the COVID-19 pandemic response on at-risk children. Pediatrics 2020;146: e20200973. 9. Panovska-Griffiths J, Kerr CC, Stuart RM, Mistry D, Klein DJ, Viner RM, et al. Determining the optimal strategy for reopening schools, the impact of test and trace interventions, and the risk of occurrence of a second COVID-19 epidemic wave in the UK: a modelling study. Lancet Child Adolesc Health 2020;4:817-27. 10. Joynt GM, Wu WK. Understanding COVID-19: what does viral RNA load really mean? Lancet Infect Dis 2020;20:635-6. 1 LETTERS TO THE EDITOR