Fecal Transmission of COVID-19 in Children? An Inside Lyme Podcast

Welcome to another Inside Lyme podcast. In this episode I discuss an early question raised during the COVID-19 pandemic: could the virus be transmitted through fecal shedding in children?

You may wonder why a COVID-19 topic appears in the Inside Lyme series. As a clinician and epidemiologist, I have long been interested in how infectious diseases spread within families and communities. Like many parents and grandparents, I was also concerned about the potential risks to children and their caregivers.

One way to understand emerging infections is by examining real-world case reports.

A family cluster of COVID-19 infections

Chan and colleagues described a family cluster of pneumonia associated with COVID-19 in the journal Lancet. Of six family members who traveled to Wuhan, five were infected with the novel coronavirus.¹

The infected individuals included a father, daughter, son-in-law, grandson, and two mothers. One additional family member who did not travel became infected after contact with the group.

The five adults developed symptoms including fever, respiratory symptoms, or diarrhea within 3–6 days after exposure.

Interestingly, a 10-year-old child in the family had no symptoms but showed ground-glass lung opacities on chest CT.

Chan and colleagues concluded that the findings were consistent with person-to-person transmission within families and healthcare settings.

Transmission questions about COVID-19 in children

Most people are familiar with respiratory transmission of COVID-19. Children can develop both upper and lower respiratory infections, according to Cruz and colleagues in Pediatrics.²

However, the same authors also raised questions about another possible transmission route.

They reported evidence of viral shedding in stool for several weeks after diagnosis. This finding raised concern about potential fecal-oral transmission of the virus, particularly among infants and young children who are not toilet-trained.

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Cai and colleagues also described prolonged viral shedding in stool in five children. Viral RNA remained detectable in feces for 18–30 days after illness onset.³

Public health challenges regarding COVID-19 in children

Another challenge is that many children with COVID-19 do not develop typical symptoms.

Dong and colleagues reported that some pediatric cases had no fever or respiratory symptoms.⁴

Instead, children sometimes presented with digestive symptoms such as:

• nausea
• vomiting
• abdominal pain
• diarrhea

Cruz and colleagues noted that prolonged viral shedding in nasal secretions and stool could have important implications for daycare centers, schools, and household contacts.

This is particularly relevant for grandparents or older caregivers who may be helping care for children.

What can we learn from these cases?

1. Children with COVID-19 may present with mild upper respiratory symptoms rather than pneumonia.
2. Some infected children may have no fever.
3. Gastrointestinal symptoms such as nausea, vomiting, abdominal pain, or diarrhea may occur.

Questions raised by these cases

1. How can clinicians and caregivers recognize COVID-19 in children who have few or no respiratory symptoms?
2. How many children with mild respiratory illness may have COVID-19?
3. What role, if any, does fecal transmission play in the spread of COVID-19?
4. Should parents, grandparents, and daycare centers be aware of potential risks related to viral shedding?

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention