We read with interest the recent systematic review on clinical features and outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children [1]. However, a major deficiency in the strategy seems to be the omission of Pediatric multisystem inflammatory syndrome (PMIS) [2]. Thus, the natural history of coronavirus disease 19 (COVID-19) in children seems innocuous. An early narrative review in the journal [3] observed that the mortality due to COVID-19 in children is rare, with majority being asymptomatic or having mild respiratory and gastrointestinal manifestations. The present systematic review [1] also substantiates that most children with COVID-19 were asymptomatic; amongst symptomatic children, only 0.7% required mechanical ventilation. The unique delayed cardiovascular manifestations in children have been omitted altogether from the suggested screening strategy for SARS-CoV-2 infection.

In these circumstances, the elucidation of clinical features and outcome using a strategy of systematic review and meta-analysis is premature. The average time for the process of a systematic review is about 17 months [4]. On the other hand, a living systematic review methodology allows minimal loss to methodological rigor. It preserves and improves the currency, relevance, and usefulness of a systematic review. Technology is often applied for arduous data extraction processes. These facilitate efficient extraction of relevant data, and fast and maintained synthesis of evidence. The benefit for researchers and policy makers is also immense [4].

The included studies in this review [1] were small and retrospective, with lot of heterogeneity and publication bias, the overall evidence generated is very low quality. Meta-analysis should be conducted with a group of homogeneous studies in terms of interventions involved and outcomes so as, to provide a meaningful summary [5].

Acknowledgement: Dr SK Vijesh for help in editing the manuscript.

1. Meena J, Yadav J, Saini L, Yadav A, Kumar J. Clinical features and outcome of SARS-CoV-2 infection in children: A systematic review and meta-analysis.　Indian Pediatr. 2020; 57:820-6.

2. Kuttiatt VS, Abraham PR, Menon PR, Vaidya PC, Rahi M. COVID-19 children: Clinical and epidemiological implications. IJMR [E-pub ahead of print June 6, 2020].

3. Balasubramanian S, Rao NM, Goenka A, Roderick M, Ramanan AV. Coronavirus disease 2019 (COVID-19) in children - What we know so far and what we do not. Indian Pediatr. 2020;57:435-42.

4. Schmidt L, Olorisade BK, McGuinness LA, et al. Data extraction methods for systematic review (semi) automation: A living review protocol [version 1; peer review: Awaiting peer review]. F1000 Research. 2020;9:210.