Main Article Content

Davide Pata
Danilo Buonsenso
Piero Valentini


SARS-CoV-2; Influenza; children; clinical features; laboratory; systematic review


Background and Objectives. Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2 and has a clinical presentation ranging from asymptomatic course to flu-like syndrome up to respiratory failure. Seasonal Influenza, due by the influenza viruses and very common in children, can cause symptoms similar to COVID-19. In order to identify clinical and laboratory characteristics that allow health-care workers to differentiate COVID-19 from Influenza, we performed a systematic review of the existing literature in the pediatric age. Methods.  The research was done via PubMed for articles published from March 2020 to October 2021, combining the MeSH words "COVID-19" and "Influenza" and "Children" and considering the suggestions of PRISMA Group.

Results. The most frequently described symptoms were fever and cough in both groups. In most studies, high fever, cough, nasal congestion or rhinorrhea, vomiting and muscle pain were detected more frequently in the Influenza group. Regarding the value of laboratory tests, the results were mixed. Almost all studies reported significantly lower levels of C-reactive protein and procalcitonin in the COVID-19 group than in the Influenza group. In most manuscripts, COVID-19 had a milder course than Influenza.

Conclusions. There are no symptoms characteristic of a single infectious agent, with flu-like disorders being the most common. In addition, laboratory tests do not help in the differential diagnosis but show a limited inflammatory response in COVID-19. This could explain the fewer complications compared to adulthood, with a less severe clinical course.

Keywords: COVID-19; Influenza; children












Download data is not yet available.

Abstract 587
PDF Downloads 484
HTML Downloads 152


1. Zhu N, Zhang D, Wang W, et al.; China Novel Coronavirus Investigating and Research Team. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020 Feb 20;382(8):727-733. doi: 10.1056/NEJMoa2001017. Epub 2020 Jan 24. PMID: 31978945; PMCID: PMC7092803.
2. Available at; accessed 06/01/2022
3. Li Y, Guo F, Cao Y, Li L, Guo Y. Insight into COVID-2019 for pediatricians. Pediatr Pulmonol. 2020 May;55(5):E1-E4. doi: 10.1002/ppul.24734. Epub 2020 Mar 18. PMID: 32187887; PMCID: PMC7167677.
4. Buonsenso D, Sali M, Pata D, et al. Children and COVID-19: Microbiological and immunological insights. Pediatr Pulmonol. 2020 Oct;55(10):2547-2555. doi: 10.1002/ppul.24978. Epub 2020 Jul 30. PMID: 32710652.
5. Available at; accessed 06/01/2021
6. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. doi: 10.1136/bmj.n71. PMID: 33782057; PMCID: PMC8005924.
7. Zhao Y, Sun L, Bouchard HC, et al. Coronavirus Disease 2019 versus Influenza A in Children: An Observational Control Study in China. Biomed Environ Sci. 2020 Aug 20;33(8):614-619. doi: 10.3967/bes2020.080. PMID: 32933613; PMCID: PMC7505108.
8. Yılmaz K, Şen V, Aktar F, Onder C, Yılmaz ED, Yılmaz Z. Does Covid-19 in children have a milder course than Influenza? Int J Clin Pract. 2021 Sep;75(9):e14466. doi: 10.1111/ijcp.14466. Epub 2021 Jun 27. PMID: 34107134; PMCID: PMC8237020.
9. Vanhems P, Endtz H, Dananché C, Komurian-Pradel F, Sanchez Picot V; Pneumonia Study GABRIEL members*. Comparison of the Clinical Features of SARS-CoV-2, Other Coronavirus and Influenza Infections in Infants Less Than 1-Year-Old. Pediatr Infect Dis J. 2020 Jul;39(7):e157-e158. doi: 10.1097/INF.0000000000002705. PMID: 32525645; PMCID: PMC7279055.
10. Sousa BLA, Sampaio-Carneiro M, de Carvalho WB, Silva CA, Ferraro AA. Differences among Severe Cases of Sars-CoV-2, Influenza, and Other Respiratory Viral Infections in Pediatric Patients: Symptoms, Outcomes and Preexisting Comorbidities. Clinics (Sao Paulo). 2020 Nov 30;75:e2273. doi: 10.6061/clinics/2020/e2273. PMID: 33263633; PMCID: PMC7688070.
11. Song X, Delaney M, Shah RK, Campos JM, Wessel DL, DeBiasi RL. Comparison of Clinical Features of COVID-19 vs Seasonal Influenza A and B in US Children. JAMA Netw Open. 2020 Sep 1;3(9):e2020495. doi: 10.1001/jamanetworkopen.2020.20495. PMID: 32897374; PMCID: PMC7489826.
12. Pokorska-Śpiewak M, Talarek E, Popielska J, et al. Comparison of clinical severity and epidemiological spectrum between coronavirus disease 2019 and influenza in children. Sci Rep. 2021 Mar 11;11(1):5760. doi: 10.1038/s41598-021-85340-0. PMID: 33707568; PMCID: PMC7952543.
13. Li Y, Wang H, Wang F, et al. Comparison of hospitalized patients with pneumonia caused by COVID-19 and influenza A in children under 5 years. Int J Infect Dis. 2020 Sep;98:80-83. doi: 10.1016/j.ijid.2020.06.026. Epub 2020 Jun 12. PMID: 32535301; PMCID: PMC7289729.
14. Liu X, Li W, Zhang B, et al. Comparative study of hospitalized children with acute respiratory distress syndrome caused by SARS-CoV-2 and influenza virus. BMC Infect Dis. 2021 May 4;21(1):412. doi: 10.1186/s12879-021-06068-w. PMID: 33947345; PMCID: PMC8093914.
15. Liu XP, Guo MM, Liu SF, Kuo HC. Comparison of laboratory data between children with COVID-19 and influenza. Kaohsiung J Med Sci. 2021 Feb;37(2):158-159. doi: 10.1002/kjm2.12353. Epub 2021 Jan 15. PMID: 33452732; PMCID: PMC8014750.
16. Liang F, Wang X, Shao J, et al. Comparison of clinical features on admission between coronavirus disease 2019 and influenza a among children: a retrospective study in China. BMC Infect Dis. 2021 Apr 17;21(1):365. doi: 10.1186/s12879-021-06037-3. PMID: 33865314; PMCID: PMC8052833.
17. Asseri AA, Shati AA, Al-Qahtani SM, et al. Distinctive clinical and laboratory features of COVID-19 and H1N1 influenza infections among hospitalized pediatric patients. World J Pediatr. 2021 Jun;17(3):272-279. doi: 10.1007/s12519-021-00432-1. Epub 2021 May 10. PMID: 33970449; PMCID: PMC8108014.
18. Kuiken T, Holmes EC, McCauley J, Rimmelzwaan GF, Williams CS, Grenfell BT. Host species barriers to influenza virus infections. Science. 2006 Apr 21;312(5772):394-7. doi: 10.1126/science.1122818. PMID: 16627737.
19. Kumlin U, Olofsson S, Dimock K, Arnberg N. Sialic acid tissue distribution and influenza virus tropism. Influenza Other Respir Viruses. 2008 Sep;2(5):147-54. doi: 10.1111/j.1750-2659.2008.00051.x. PMID: 19453419; PMCID: PMC4941897.
20. Buonsenso D, Sali M, Pata D, et al. Children and COVID-19: Microbiological and immunological insights. Pediatr Pulmonol. 2020 Oct;55(10):2547-2555. doi: 10.1002/ppul.24978. Epub 2020 Jul 30. PMID: 32710652.
21. Osman M, Klopfenstein T, Belfeki N, Gendrin V, Zayet S. A Comparative Systematic Review of COVID-19 and Influenza. Viruses. 2021 Mar 10;13(3):452. doi: 10.3390/v13030452. PMID: 33802155; PMCID: PMC8001286.
22. Smith C, Odd D, Harwood R, et al. Deaths in children and young people in England after SARS-CoV-2 infection during the first pandemic year. Nat Med. 2021 Nov 11. doi: 10.1038/s41591-021-01578-1. Epub ahead of print. PMID: 34764489.
23. Bogunovic D, Merad M. Children and SARS-CoV-2. Cell Host Microbe. 2021 Jul 14;29(7):1040-1042. doi: 10.1016/j.chom.2021.06.015. PMID: 34265242; PMCID: PMC8279573.
24. Duarte-Salles T, Vizcaya D, Pistillo A, et al. Thirty-Day Outcomes of Children and Adolescents With COVID-19: An International Experience. Pediatrics. 2021 Sep;148(3):e2020042929. doi: 10.1542/peds.2020-042929. Epub 2021 May 28. PMID: 34049958.
25. Pata D, Valentini P, De Rose C, De Santis R, Morello R, Buonsenso D. Chest Computed Tomography and Lung Ultrasound Findings in COVID-19 Pneumonia: A Pocket Review for Non-radiologists. Front Med (Lausanne). 2020 Jun 26;7:375. doi:10.3389/fmed.2020.00375. PMID: 32671086; PMCID: PMC7332745.
26. Buonsenso D, Pata D, De Rose C, et al. Clinical application of Lung Ultrasound for the management of pregnant women with suspicion of COVID-19: a review of literature. J.Gynecol. Obstet. 2020, 32, N.3. doi: 10.36129/jog.32.03.04