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May 12: Children suffering from non-respiratory disease symptoms like diarrhea and fever, or those with a history of exposure to the novel coronavirus, should be suspected of having COVID-19, a new study says.

According to the research, published in the journal Frontiers in Pediatrics, gastrointestinal symptoms first suffered by some children hints at potential infection with SARS-CoV-2 through the digestive tract.

"This case series is the first report to describe the clinical features of COVID-19 with non-respiratory symptoms as the first manifestation in children," the scientists from Tongji Hospital in China wrote in the study.

They explained that the gastrointestinal symptoms could be arising since the type of receptors in lung cells targeted by the virus can also be found in the intestines.

Most children are only mildly affected by COVID-19, and the few severe cases often have underlying health issues, the researchers said.

"It is easy to miss its diagnosis in the early stage, when a child has non-respiratory symptoms, or suffers from another illness," said study co-author Wenbin Li, who works at the Department of Pediatrics, Tongji Hospital.

"Based on our experience of dealing with COVID-19, in regions where this virus is epidemic, children suffering from digestive tract symptoms, especially with fever and/or a history of exposure to this disease, should be suspected of being infected with this virus," Li said.

In the study, the scientists described the clinical features of children admitted to hospital with non-respiratory symptoms, who were subsequently diagnosed with pneumonia and COVID-19.

"These children were seeking medical advice in the emergency department for unrelated problems, for example, one had a kidney stone, another a head trauma," Li said.

The study noted that all the children had pneumonia, which was confirmed by chest X-ray scan before or soon after admission.

These children were then confirmed to have COVID-19.

While their COVID-19 symptoms were initially mild or relatively hidden before their hospital admission, four out of the five cases had digestive tract symptoms as the first manifestation of this disease, the researchers said.

Li hopes that doctors will use the findings to quickly diagnose and isolate patients with similar symptoms, which may aid early treatment and reduce transmission.

According to the researchers, the children's gastrointestinal symptoms, which have also been recorded in adult patients, could be an additional route of infection.

"The gastrointestinal symptoms experienced by these children may be related to the distribution of receptors and the transmission pathway associated with COVID-19 infection in humans," Li explained.

Since the virus infects people via the ACE2 receptor, which can be found in certain cells in the lungs as well as the intestines, COVID-19 might infect patients not only through the respiratory tract in the form of air droplets, but also through the digestive tract by contact or fecal-oral transmission, the study noted.

While COVID-19 tests can occasionally produce false positive readings, Li said all the five children assessed in the study were infected with the disease.

However, he cautioned that more research is needed to confirm their findings.

"We report five cases of COVID-19 in children showing non-respiratory symptoms as the first manifestation after admission to hospital. The incidence and clinical features of similar cases needs further study in more patients," he said.

Thiruvananthapuram, Feb 6: The Kerala government on Wednesday said three foreign nationals were among the 2,528 people under observation in the state for the novel coronavirus infection and no new cases have been reported.

At least 93 people with minor symptoms of the virus have been lodged in isolation wards of various hospitals, state Health Minister KK Shailaja told reporters in Thiruvananthapuram.

India's three positive cases for the virus has been from the state's three districts of Thrissur, Alappuzha and Kasaragod.

All the three are students of China's Wuhan university, the epicentre of the virus.

"No new cases of coronavirus has been detected in the state today. At least 2,435 are under observation at home while 93 are in isolation wards at various hospital across the state," Mr Shailaja said.

The minister also said two foreigners have been quarantined in Ernakulam district and one foreign national at Thiruvananthapuram.

"The foreigner in Thiruvananthapuram has been kept at general hospital but not because he was showing symptoms but for observation as he travelled from China," an official said.

The health status of the three patients, who had tested positive for the virus, "remains satisfactory", the minister said.

After three cases were reported, the Left Democratic Front (LDF) government had declared the epidemic as a "state calamity" on Monday.

The health department has issued advisories to the education, tourism and the animal husbandry departments on taking precautions.

"The students, teachers, other staff members residing with families of Wuhan/China returnees who are already in home isolation should not attend classes...," an advisory issued to the education department read.

Rajan Khobragade, Principal Secretary (Health), said the health department has directed the District collectors to hold a meeting with the religious leaders of the district to create awareness during prayer meetings.

"We have directed district collectors to meet religious leaders and talk to them about the seriousness of the situation and create awareness among them and their followers on how to contain the spread of virus," the minister said.

Mr Shailaja also said the department got messages from some Kerala students studying in China, who returned to the state after the virus outbreak, that their Universities had asked them to return and attend classes.

"We have got some messages from the students that they were being recalled by the universities in China. We discussed the matter and it was decided that the centre will contact such universities and convey the message that it was not possible to send the students back to China until the epidemic was under control," the minister said.

Mr Shailaja also said even though there were no positive cases for the second consecutive day on Wednesday, the state needs to remain vigilant and reiterated the 28 days quarantine period for those returning from China.

Of the 2,528 people under observation, the maximum number is from Malappuram (383), followed by Ernakulam (333), Kozhikode (306) and Thrissur (241).