\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[greek,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Clinical Outcomes of Pfizer-BioNTech COVID-19 Vaccine on Children and
Adolescents: Where do we Stand?}



\author[1]{Ahmad  Al-Qudimat}%
\author[1]{Raed  Al-Zoubi}%
\author[1]{Mai  Elaarag}%
\author[1]{Abdulqadir Nashwan}%
\author[1]{Afaf  Hamze}%
\author[2]{Hiba  Bawadi }%
\author[1]{Aksam  Yassin}%
\author[1]{Aseel  Assim}%
\author[1]{Omar   Aboumarzouk}%
\author[1]{Ahmad  Zarour}%
\author[1]{Abdulla  Al-Ansari}%
\affil[1]{Hamad Medical Corporation}%
\affil[2]{Qatar University}%


\vspace{-1em}



  
  \date{May 04, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Background: The BioNTech-Pfizer vaccine is the only vaccine offered to
children among all available vaccines. However, limited evidence is
available about the clinical outcomes of COVID-19 vaccines, especially
among children and adolescents. This review offers a comprehensive and
up-to-date overview of the BioNTech-Pfizer vaccine's current information
on children and adolescents. Methods: The review was conducted following
the PRISMA guidelines; a comprehensive search was performed in PubMed,
Scopus, MEDLINE, and EMBASE databases for research publications COVID-19
published between December 2019 and October 2021. All studies reporting
on the outcomes of vaccinating children in their respective institutes
were included. Results: A total of 78 vaccinated children and
adolescents from 6 studies were included. The majority of symptomatic
vaccinated pediatrics were males (71\%). The mean age was 15.6 years,
and the BMI was 24.1. The most common clinical symptoms were found in
chest pain (35\%), fever (32\%), and myalgia (17\%). The most common
cardiac symptom in the EKG results was ST elevation, and 35\% of
vaccinated pediatrics had elevated serum troponin. The hospitalization,
including ICU admission, was lower than in unvaccinated groups.
Statistically significant associations (P = \textless{}0.05) were found
in two symptoms (fever and headache) between the vaccinated and
non-vaccinated pediatric groups. Conclusions: Although we found better
outcomes in the vaccinated group versus the non-vaccinated pediatric
group, more studies are still crucial to further understand the specific
etiology underlying post-vaccination, particularly myocarditis,
psychological impact, and other cardiac clinical symptoms in children
and adolescents after receiving the BioNTech-Pfizer vaccine.%
\end{abstract}%



\sloppy


\textbf{Clinical Outcomes of Pfizer-BioNTech COVID-19 Vaccine on
Children and Adolescents: Where do we Stand?}

Ahmad R. Al-Qudimat\textsuperscript{{[}1{]}}, Raed M.
Al-Zoubi\textsuperscript{{[}1,2,3{]}}, Mai
Elaarag\textsuperscript{{[}1{]}}, Abdulqadir J.
Nashwan\textsuperscript{{[}10{]}}, Afaf K.
Hamze\textsuperscript{{[}4{]}}, Hiba Bawadi \textsuperscript{{[}2{]}},
Aksam Yassin\textsuperscript{{[}1,5{]}}, Aseel
Assim\textsuperscript{{[}6{]}}, Omar M.
Aboumarzouk\textsuperscript{{[}1,7,8{]}} , Ahmad
Zarour\textsuperscript{{[}9{]}}, Abdulla
Al-Ansari\textsuperscript{{[}1,6{]}}

\textbf{Author list:}

\textsuperscript{{[}1{]}} Surgical Research Section, Department of
Surgery, Hamad Medical Corporation, Doha, Qatar

\textsuperscript{{[}2{]}} Department of Biomedical Sciences, College of
Health Sciences, QU-Health; Qatar University, Doha, 2713, Qatar

\textsuperscript{{[}3{]}} Department of Chemistry, Jordan University of
Science and Technology, P.O.Box 3030, Irbid, 22110, Jordan

\textsuperscript{{[}4{]}} Hamad Medical Corporation, Doha, Qatar

\textsuperscript{{[}5{]}} Center of Medicine and Health Sciences,
Dresden International University, Dresden, Germany

\textsuperscript{{[}6{]}} Hamad General Hospital, Hamad Medical
Corporation, Qatar, Doha

\textsuperscript{{[}7{]}} College of Medicine, QU-Health; Qatar
University, Doha Qatar

\textsuperscript{{[}8{]}} School of Medicine, Dentistry and Nursing, The
University of Glasgow, Glasgow, UK

\textsuperscript{{[}9{]}} Acute care Surgery Division, Department of
Surgery, Hamad Medical Corporation, Doha, Qatar

\textsuperscript{{[}10{]}} Nursing Department, Hamad Medical
Corporation, Doha, Qatar

\textbf{ORCID ID:}

Ahmad R. Al-Qudimat 0000-0003-1161-7244

Raed M. Al-Zoubi 0000-0002-0548-429X

Mai Elaarag 0000-0001-6192-5654

Abdulqadir Nashwan* 0000-0003-4845-4119

Afaf K. Hamze NA

Hiba Bawadi 0000-0003-1499-5646

Aksam Yassin 0000-0001-5457-3443

Aseel Assim NA

Omar M. Aboumarzouk 0000-0002-7961-76140000-0001-5457-3443

Ahmad Zarour 0000-0003-1161-7244

Abdulla Al-Ansari 0000-0002-6242-5667

\textbf{Corresponding Authors:}

* Abdulqadir J. Nashwan, Hamad Medical Corporation, Doha, Qatar.
anashwan@hamad.qa

\textbf{Author contribution:} ARA, ME, and AKH literature search,
collected and interpreted the data. AY, AA, OMA, ARA, AJN and RMA
drafted the work and contributed to the writing of this manuscript. RMA,
AJN and OMA edited and drafted the final version of this manuscript. AA,
AZ, and HB reviewed the draft.

\textbf{Abbreviated title:} Latest updates on Pfizer-BioNTech COVID-19
Vaccine for children and Adolescents

\textbf{Keywords:} Pfizer-BioNTech, COVID-19, Vaccine, Children,
Adolescents, BNT162b2, Symptoms

\textbf{Abstract:}

Background: The BioNTech-Pfizer vaccine is the only vaccine offered to
children among all available vaccines. However, limited evidence is
available about the clinical outcomes of COVID-19 vaccines, especially
among children and adolescents. This review offers a comprehensive and
up-to-date overview of the BioNTech-Pfizer vaccine's current information
on children and adolescents.

Methods: The review was conducted following the PRISMA guidelines; a
comprehensive search was performed in PubMed, Scopus, MEDLINE, and
EMBASE databases for research publications COVID-19 published between
December 2019 and October 2021. All studies reporting on the outcomes of
vaccinating children in their respective institutes were included.

Results: A total of 78 vaccinated children and adolescents from 6
studies were included. The majority of symptomatic vaccinated pediatrics
were males (71\%). The mean age was 15.6 years, and the BMI was 24.1.
The most common clinical symptoms were found in chest pain (35\%), fever
(32\%), and myalgia (17\%). The most common cardiac symptom in the EKG
results was ST elevation, and 35\% of vaccinated pediatrics had elevated
serum troponin. The hospitalization, including ICU admission, was lower
than in unvaccinated groups. Statistically significant associations (P =
\textless{}0.05) were found in two symptoms (fever and headache) between
the vaccinated and non-vaccinated pediatric groups.

Conclusions: Although we found better outcomes in the vaccinated group
versus the non-vaccinated pediatric group, more studies are still
crucial to further understand the specific etiology underlying
post-vaccination, particularly myocarditis, psychological impact, and
other cardiac clinical symptoms in children and adolescents after
receiving the BioNTech-Pfizer vaccine.

\textbf{Abbreviations} :

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

World Health Organization (WHO)

The Preferred Reporting Items for Systematic Reviews (PRISMA)

Middle East respiratory syndrome coronavirus (MERS-CoV)

Ribonucleic acid~(RNA)

Messenger RNA~(mRNA)

Deoxyribonucleic acid (DNA)

Food and Drug Administration (FDA)

Intensive care unit~(ICU)

United States of America (USA)

Body mass index~(BMI)

Electrocardiogram (ECG or EKG)

Congenital Valvular Disease (CVD)

Magnetic resonance imaging~(MRI)

Late Gadolinium Enhancement (LGE)

Morbidity and Mortality Weekly Report (MMWR)

\textbf{Conflict of Interest:} All authors declare there is no conflict
of interest\textbf{.}

\textbf{Funding:} None

Acknowledgment: The publication of this article was funded by Qatar
National Library.

\textbf{Clinical Outcomes of Pfizer-BioNTech COVID-19 Vaccine on
Children and Adolescents: Where do we Stand?}

\textbf{Introduction}

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has
swiftly spread around the world, causing a global pandemic (COVID-19)
declared by the World Health Organization (WHO). COVID-19 resulted in a
significant increase in morbidity and death, as well as significant
economic damage (1). As of November 20\textsuperscript{th}, 2021, there
have been more than 257 million confirmed cases and more than 5 million
death cases reported to WHO.

The highly contagious coronavirus strain has overwhelmed the global
healthcare systems for the third time in this century. The first
coronavirus pandemic was started in 2002 by a severe acute respiratory
syndrome coronavirus (SARS-CoV-1). As a result, healthcare workers were
at a higher risk of developing the disease than others in the population
(2). In 2012, Middle East respiratory syndrome coronavirus (MERS-CoV)
spread globally, causing the second outbreak. According to the World
Health Organization, the MERS-CoV virus is still circulating with a 35\%
fatality rate compared to 9.5\% for SARS-CoV-1 (1). SARS-CoV-1 has a
case fatality rate of 2\%--3\%, according to reports (3).

Nowadays, the world suffers from the third coronavirus infection
(SARS-CoV-2) and causing severe acute respiratory syndrome (4-6). It
began back in December 2019, when Chinese health officials in Wuhan
discovered severe respiratory distress due to pneumonia in a cluster of
people. On Jan 7\textsuperscript{th}, 2020, the new coronavirus strain
dubbed novel coronavirus 2019 came from these patient clusters
(2019-nCoV).

In the united states (US) alone, 9--12\% of diagnosed patients with
COVID-19 were Children (7). About 90\% of children who tested positive
were asymptomatic or had mild-to-moderate symptoms. Only 15 children
required critical care in a survey of 2572 pediatric cases, with three
deaths documented (8). Another study across North America found that 18
of 48 children brought to ICUs required invasive ventilation, where 16
children survived and two died (9). Children under the age of one year,
as well as those with additional comorbidities or underlying diseases,
were found to be at higher risk of severe illness (10-12). It is
suggested that COVID-19 in the pediatric population was less severe
compared to cases in adults, and diagnosed children had different
symptoms than adults do (13, 14). Interestingly, children might not have
coughing or fever as frequently reported in adults (14).

Vaccinations and preventive measures are crucial for all ages to protect
children from new variants of this virus-like Delta and Omicron and for
patients with comorbidities and to have more control over disease
transmission.

Accordingly, WHO granted a global emergency approval of vaccines (15).
The fast development of COVID-19 vaccines raised many concerns and
questions. In 2020 and during this pandemic, the mRNA type of vaccines
have been used on humans and showed a significant efficacy rate (16-20).

The BioNTech-Pfizer COVID-19 vaccine is developed from a single-stranded
mRNA made in vitro transcription from a DNA template that encodes the
viral spike protein (21).

This review aims to offer healthcare workers and non-healthcare workers
a comprehensive and up-to-date overview of the currently available
information about the BioNTech-Pfizer vaccine on children and
adolescents. Also, to provide the scientific readers with useful data
that can aid in early recognition and effective prevention and
management of children affected by COVID-19 and the BioNTech-Pfizer
vaccine.

\textbf{Methods}

A systematic review was conducted in accordance with the Preferred
Reporting Items for Systematic Reviews (PRISMA) guidelines (22), a
comprehensive search was performed in PubMed, Scopus, MEDLINE, and
EMBASE Databases for research publications on COVID-19 published between
December 2019 and October 2021 using the terms COVID-19, Pediatrics,
children, adolescents, SARS-CoV-2, Epidemiology, and Vaccine. Phrases
used for the Medical Subject Heading {[}MeSH{]} search included:
(((``COVID-19'' {[}MeSH{]}) and ``Vaccine'' {[}MeSH{]}) and ``Children''
{[}MeSH{]}) and ``adolescents'' {[}MeSH{]}) and ``Pfizer'' {[}MeSH{]}.
We focused on original research, case reports, case series, and
vaccination side-effect by authoritative health institutions. All
records were retrieved, including original articles, letters to the
editor, editorials, and case reports, in English, and records with
English translation were downloaded and reviewed. Given the current
scarcity of evidence, preprints, in-press papers, and
accepted-for-publication research were also considered.

\textbf{Inclusion criteria}

Studies were included for the systematic review if they met the
following criteria (a) infants, children, and adolescents who had
COVID-19 vaccinated by BioNTech-Pfizer vaccine; (b) children and
adolescents who had COVID-19, either confirmed microbiologically or
clinically, especially those vaccinated by BioNTech-Pfizer vaccine; (c)
information on COVID-19 outcome was reported as either ICU admission
(ICU and intermediate care), or hospitalization; (d) at least one side
effect after receiving BioNTech-Pfizer vaccine.

\textbf{Search Strategy}

Study selection \& data collection

Through abstract screening, the previously indicated inclusion criteria
were applied to choose possibly relevant articles. Two authors (A.R.A.
and O.M.R.) assessed full texts of relevant articles and screened them
according to the inclusion criteria. Where there was a difference of
opinions, conversations with the senior authors (O.M.A. and R.M.A.) were
held until a consensus was established.

Data extraction

We extracted as many relevant variables as possible from the information
provided (age, date, etc.) and according to the main stratification
variable, author, country, data source, age range, study timeframe,
baseline population group, outcome (symptoms after vaccination, severity
symptoms), total sample, others. We additionally included another
category of the length of stay in the hospital or ICU. We retrieved data
on the age who are confirmed vaccinated by BioNTech-Pfizer COVID-19,
confirmed symptoms after vaccination, and length of stay in hospitals or
ICU from publicly available data. All studies included in this review
were published in the United States of America (USA).

\textbf{Results}

The initial literature search retrieved 162 potentially relevant
studies. After initial screening, 1 study was excluded due to
duplication, and 155 studies were further excluded after reviewing the
title, abstract, or not meeting the eligibility criteria. Only 6 studies
were relevant and included in the review (Fig.1).

\textbf{Figure 1} . PRISMA diagram of literature search.

Risk of Bias Assessment

Since only non-randomized studies are included in this review, one risk
of bias assessment was performed. Two researchers worked together to
complete the risk of bias assessment; after that, a third researcher
compared and integrated the findings of this assessment. If there was
any disagreement, the fourth investigator acted as tie-breaker. The Risk
of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool was
used to perform the risk assessment.

According to the traffic light plot of the risk of bias assessment
(non-randomized studies), 81\% had a low risk of bias (Table 1). 2 out
of 6 studies were found to have a moderate risk of bias. None of the
studies were found to have a critical risk of bias.

\textbf{Table 1} . Traffic Light Plot of Risk of Bias Assessment
(Non-Randomized Studies)\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D1}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D2}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D3}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D4}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D5}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D6}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{D7}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Studies}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Marshall et al., 2021\textsuperscript{(19)}}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Moeller et al., 2021\textsuperscript{(20)}}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Tano et al., 2021\textsuperscript{(25)}}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Schauer et al., 2021~\textsuperscript{(22)}}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Dionne et al., 2021~\textsuperscript{(23)}}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Hanna et al., 2021\textsuperscript{(24)}}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Domains}: D1: Bias due to confounding. B2: Bias due to selection
of participants. B3: Bias in classification of interventions. B4: Bias
due to deviations from intended intervention. B5: Bias due to missing
data. B6: Bias in measurement of outcomes. B7: Bias in selection of the
reported result\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Judgement:}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\textbf{Judgement:}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Low}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Moderate}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Ethical Considerations

The ethical review was deemed unnecessary due to the nature of this
study (a systematic review). However, all data were confidentiality
observed and protected. All data used in this review were accessed and
evaluated only by the researchers and kept on personal
password-protected computers. The protocol for this systematic review
was registered in the International Prospective Register of Systematic
Reviews (PROSPERO) with a unique ID: CRD42021297129.

Study Characteristics and Cumulative Analysis

In total, 6 reports were included in this study (23-28). There were no
randomized trials, and all studies were observational
(retrospective\textbf{,~} case series, and case report) as shown in
Table 2. A total of~78~vaccinated children~and adolescents~were
included.~Gender was provided for all patients and included~55~males and
23 females. The mean age was 15.6, ranging between 14.5 to 18 years old.
A total of 66 out of 78 patients were found to be White and the dominant
race in the analysis. One median was provided by one study and was not
calculated in the analysis. BMI was included in only two studies.

The clinical symptoms of the BioNTech-Pfizer vaccine on vaccinated
children and adolescents are demonstrated in Table 3.~The symptoms of
vaccinated children and adolescents were listed and summarized. The most
common clinical symptoms were found in chest pain (35\%), fever (32\%),
myalgia/muscle pain (17\%), headache (8\%)~ , fatigue (13\%), SOB
(17\%), vomiting (5\%),~nausea~(4\%),~malaise~(4\%) and local
pain~(3\%).

\textbf{Table 2} . Summary of relevant research studies and
characteristics of vaccinated children and adolescents after
BioNTech-Pfizer COVID-19 vaccine\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
Author, Year & Country & Study Design & Pediatric patients & Enrollment
period & Age (mean) & Gender (M/F) & Race & BMI (mean)\tabularnewline
\midrule
\endhead
Marshall et al., 2021\textsuperscript{(23)} & USA & case report & 7 &
(April to May 2021) & 16.7 & 7/0 & 6 white, 1~Hispanic &
22\tabularnewline
Moeller et al., 2021\textsuperscript{(24)} & USA & retrospective & 33 &
(May to June, 2021) & 14.5 & 12/21 & 30 white, 1 black, 2 others &
N\textsubscript{S}\tabularnewline
Tano et al., 2021\textsuperscript{(25)} & USA & case series & 8 & (May,
2021) & 16.6 & 8/0 & 8 white & 26.2\tabularnewline
Schauer et al., 2021~\textsuperscript{(26)} & USA & retrospective & 13 &
(April to June, 2021) & 15.1 & 12/1 & 10 white, 2~Asian, 1~Alaska~native
& N\textsubscript{S}\tabularnewline
Dionne et al., 2021~\textsuperscript{(27)} & USA & case series & 15 &
(May to July, 2021) & 15 (12-18)* & 14/1 & 10 white, 5 others &
N\textsubscript{S}\tabularnewline
Hanna et al., 2021\textsuperscript{(28)} & USA & case report & 2 & (May,
2021) & 15 & 2/0 & 2 white & N\textsubscript{S}\tabularnewline
Total & & & \textbf{78} & & \textbf{14.5-18**} & \textbf{55/23} &
\textbf{66 white, 1 black, 1~Hispanic, others} &\tabularnewline
\bottomrule
\end{longtable}

*~ Median, ** Range, N\textsubscript{S}: Not stated

For instance, Hanna et al. reported a study of 2 pediatric patients with
IgAN presenting with microscopic hematuria less than 24 hrs after
receiving the BioNTech-Pfizer vaccine. The authors found a 13-year-old
male patient had a history of IgAN~and type 1 diabetes, whereas the
other male patient in this study was found~healthy with no medical
history before receiving the vaccine (28).~Children and adolescents'
clinical cardiac symptoms are also demonstrated in~Table 3.~It included
the~abnormal EKG~and~echocardiogram, abnormal cardiac MRI~findings
including~pericardial effusion,~and high troponin levels.~It is worth
noting that troponin levels were elevated in 35\% of patients (23,
25-27). However, no testing showed pericardial effusion. The most common
EKG result was ST elevation. Marshall et al. reported atrioventricular
dissociation with junctional escape rhythm, T-wave abnormality, and
sinus~bradycardia(23).~Moreover, Tano et al. found in their study that
among patients who had EKG,~~2 had RP depression,~1 had~abnormal
waves,~and 1 had~ST depression~and~conduction~delay(25). The abnormal
echocardiogram outcomes were included in 3 studies (23, 26, 27).~For
instance,~Marshall et al. reported in their study that only one patient
had mildly depressed RV and LV systolic function (LVEF 47\%) and basal
lateral and posterior strain (23). Ejection fraction was reported
by~Schauer et al. (26) and Tano et al. (25) for 13 and 8 patients,
respectively. Moeller et al. reported the psychological symptoms of
children and~adolescents after having the BioNTech-Pfizer vaccine(24).
Their study included 33 pediatric patients, 3 of them had anxiety, 3 had
attention deficit or hyperactivity,~4 had disruptive mood dysregulation
disorder, and 18 of them had a major depressive disorder or suicidal
ideation.

\textbf{Table 3.} Clinical Signs and Symptoms on Children and
Adolescents After BioNTech-Pfizer COVID-19 Vaccine\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllllllllll@{}}
\toprule
\begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Author, Year\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage} & \begin{minipage}[b]{0.03\columnwidth}\raggedright\strut
Children and Adolescents' Clinical Signs and Symptoms After Second Dose
of BioNTech-Pfizer COVID-19 Vaccine (BNT162b2)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Patients~No.}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Gender (M/F)}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Fever}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Fatigue~}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Headache}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Nausea}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Vomiting}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{SOB}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Myalgia}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Weakness/}\\
\textbf{Malaise}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Chest Pain}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Local Pain}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Abnormal EKG/ECG ~}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Abnormal Echocardiogram~}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Cardiac MRI}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Cardiac MRI}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Cardiac MRI}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Abnormal Troponin}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{MRI No.}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Cardiac MRI~} \textbf{Edema}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\textbf{Cardiac MRI LGE}\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Marshall et al., 2021\textsuperscript{(23)}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
7/0\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Moeller et al., 2021\textsuperscript{(24)}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
33\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
12/21\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{A}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Tano et al., 2021\textsuperscript{(25)}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
8/0\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Schauer et al., 2021~\textsuperscript{(26)}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
12/1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
13\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Dionne et al., 2021~\textsuperscript{(27)}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
14/1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Hanna et al., 2021\textsuperscript{(28)}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
2/0\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
N\textsubscript{S}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
Total\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{78}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{55/23}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{25}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{10}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{6}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{3}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{4}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{13}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{13}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{3}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{27}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{2}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{30}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{5}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{38}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{22}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{34}\strut
\end{minipage} & \begin{minipage}[t]{0.03\columnwidth}\raggedright\strut
\textbf{27}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{N\textsubscript{S}} : Not stated. \textbf{N\textsubscript{A}} :
Not applicable

The hospitalization of 78 vaccinated children and adolescents was also
investigated. Among the vaccinated pediatrics during the period from
April to July, 2021, and according to 6 studies (23-28), for whom
clinical data are completed and available, 45 (58\%) were hospitalized,
and 5 (6.4\%) were admitted to ICU. The range of hospital stay for
vaccinated pediatrics was found to be 1-6 days.

The difference in clinical symptoms/signs between vaccinated and
non-vaccinated pediatrics is shown in Table. 4. Symptoms were found
milder in vaccinated pediatrics compared to the diagnosed COVID-19
pediatrics. For instance, none of the vaccinated pediatrics had cough
symptoms compared to 51\% (150/297) of non-vaccinated pediatrics. Only
32\% (25/78) of vaccinated pediatrics had fever compared to 55\%
(163/297) of the non-vaccinated group. 17\% (13/78) had SOB compared to
13\% (39/297). 17\% (13/78) of vaccinated pediatrics had muscle pain
compared to 22\% (66/297) for non-vaccinated pediatrics. Headache was
only reported in 8\% (6/78) compared to 27\% (81/297) for the
non-vaccinated group. Lastly, 9\% (7/78) of the vaccinated group had
nausea/vomiting compared to 10\% (31/297).

\textbf{Table} \textbf{4.} Percentage of signs and symptoms among 78
vaccinated pediatric (age\textless{}18 years) with BioNTech-Pfizer
vaccine and 297 non-vaccinated pediatric (age\textless{}18 years, Lab
confirmed COVID-19) in North America.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Sign/Symptom & No. (\%) of Pediatric Patients & No. (\%) of Pediatric
Patients & No. (\%) of Pediatric Patients\tabularnewline
\midrule
\endhead
& \textbf{Vaccinated (n=78)\textsuperscript{{[}23-28{]}}} &
\textbf{Non-vaccinated (n=297)\textsuperscript{{[}5{]}}} &
\textbf{P-Value}\tabularnewline
\emph{Fever} & 25 (\textbf{32\%}) & 163 (\textbf{55\%}) &
\textless{}0.001\tabularnewline
\emph{Cough} & 0 (\textbf{0\%}) & 150 (\textbf{51\%}) & -\tabularnewline
\emph{SOB} & 13 (\textbf{17\%)} & 39 (\textbf{13\%}) &
0.421\tabularnewline
\emph{Muscle~Pain} & 13 (\textbf{17\%}) & 66 (\textbf{22\%}) &
0.284\tabularnewline
\emph{Headache} & 6 (\textbf{8\%}) & 81 (\textbf{27\%}) &
\textless{}0.001\tabularnewline
\emph{Nausea/Vomiting} & 7 (\textbf{9\%}) & 31 (\textbf{10\%}) &
0.703\tabularnewline
\bottomrule
\end{longtable}

A Pearson's Chi-squared test (\selectlanguage{greek}χ\selectlanguage{ngerman}² test) showed statistically significant
associations (P = \textless{}0.05) in two symptoms (fever and headache)
between the vaccinated and non-vaccinated groups (Table 4).
Additionally, no cough symptom was reported for the vaccinated group
compared to 51\% (150/297). There was a decrease in fever in the
vaccinated group (from a mean of 163 {[}55\%{]} to 25 {[}32\%{]}, P =
\textless{}0.001) and in headache from (a mean of 81 {[}27\%{]} to 6
{[}8\%{]}, P = \textless{}0.001). No other statistically significant
associations are observed with other symptoms between the two groups.
For instance, a mean of 13 (17\%) for both SOB (P = 0.421) and
muscle~pain (P = 0.284), 7 (9\%) for nausea/vomiting (P = 0.703) for the
vaccinated group compared to a mean 39 (13\%), 66 (22\%) and 31 (10\%)
in the non-vaccinated group respectively.

\textbf{Discussion}

This article is a comprehensive review of up-to-date clinical findings
of the BioNTech-Pfizer vaccine on children and adolescents. We aimed to
provide knowledge through the evaluation of existing evidence regarding
the BioNTech-Pfizer vaccine on children and adolescents. All published
articles were found using a thorough search strategy on three databases
(PubMed, Scopus, MEDLINE, and EMBASE Databases) on October 17, 2021, and
without restrictions to language or regional. Although children and
adolescents have higher levels of antibodies and their immune system
response to pathogens is different than adults and most of them have
less severe or asymptomatic COVID-19 cases (13), some symptoms were
reported for this group after vaccination. The preliminary clinical
outcomes of vaccinated children and adolescents suggest common mild
symptoms such as fever and headache but also worth noting that some
other symptoms such as chest pain is reported, which require further
studies and health concerns. The final results~of signs and symptoms
included~78 vaccinated children and adolescents from 6 studies.

A recent report from Morbidity and Mortality Weekly Report (MMWR)
revealed that the hospitalization of COVID-19 related pediatrics during
the week ending of August 14\textsuperscript{th}, 2021 was approximately
5 times the rate of the week ending of June 26\textsuperscript{th}, 2021
(29). Moreover, the authors showed that among the children of age 0-4
years during the week ending of August 14\textsuperscript{th}, 2021 was
approximately 10 times higher than of the same age by the week ending of
June 26\textsuperscript{th}, 2021. In addition, the hospitalization of
unvaccinated adolescents of age 12-17 years during the period from June
20-July 31, 2021 was 10.1 times higher than the vaccinated adolescents.
The rate of hospitalization for COVID-19--associated pediatrics
increased rapidly with the predominance of the Delta variant from June
26 -- August 14, 2021. In this study, we found that the hospitalization
of vaccinated pediatrics (78 patients) in 6 studies and from April to
July, 2021 were less compared to the unvaccinated group. A total of 37
(47\%) were hospitalized with a mean range of hospital stay between 1-6
days for the vaccinated pediatrics. ICU admission was reported only for
5 (6.4\%) and in only one article with ICU stay for 2-5 days.

Pfizer performed a phase III clinical trial to study the effectiveness
of their vaccine. In this study, 2260 children aged from 12 to 15 years
were enrolled, only 18 cases of COVID-19 were recorded for the placebo
group (n=1129) and none were reported for the vaccinated group (n=1131).
Accordingly, the study led to FDA approval of expanding the use to
children aged 12 to 15 years (21). Pfizer announced that their COVID-19
vaccine will be 100\% efficient in children aged 12 to 15 (30). This
emergency use authorization by FDA to include children of 12 to 15 years
of age was a significant step in our fight against this virus.
Currently, trial studies are still ongoing to further test the vaccine's
efficacy on younger children aged 6 months to 11 years (30).

Clinical symptoms

The most common clinical symptoms of vaccinated pediatric patients were
found 27 had chest pain (35\%), 25 had fever (32\%), 6 had headache
(8\%), and~10 had fatigue (13\%). All other symptoms are summarized in
Table 3. In addition, the majority (71\%) of symptomatic vaccinated
pediatrics were males. The average length of hospitalization is 1-6
days. Although a number of diagnosed pediatrics with COVID-19 required
ICU level care, the number of pediatrics who need ICU level care after
vaccinations was only reported in one study to date (23).

Galindo et al. reported a study on the most common COVID-19 symptoms
among pediatrics(31). Authors looked up at 333 pediatric patients who
were diagnosed with COVID-19 and found that fever, cough, and sore
throat were listed as the most common symptoms. The signs and symptoms
of the COVID-19 pediatrics were found to be noticeable to those who had
the BioNTech-Pfizer vaccine. The difference between vaccinated and
non-vaccinated pediatrics is summarized in Table 4. For instance, fever
presented in only 32\% of vaccinated pediatrics compared to 56\% of
non-vaccinated and diagnosed COVID-19 pediatrics. No cough symptom was
reported for the vaccinated group compared to 55\% for non-vaccinated
pediatrics. 17\% of vaccinated pediatrics had muscle pain compared to
22\% of non-vaccinated pediatrics. All other signs were also found
milder in the vaccinated group. Statistically significant associations
(P = \textless{}0.05) were found in two symptoms (fever and headache)
between the vaccinated and non-vaccinated pediatric groups (Table 4).
Fever and headache symptoms were found highly significant between the
two groups (P = \textless{}0.001).

A substantial percentage of children who were diagnosed with COVID-19
are asymptomatic. However, Fever, nasal congestion/rhinorrhea, dyspnea,
loss of smell and taste, cough, sore throat, diarrhea, nausea/vomiting,
weariness, headache, myalgia, and poor feeding/poor appetite are the
most common symptoms (14) (13). Ji et al. reported the only presenting
diarrhea symptom in only one pediatric case (32). Additionally, Wei et
al. reported that only 50\% of 9 hospitalized newborns in China with
confirmed COVID-19 had fever (33).

It is worth noting that vaccinated pediatrics presented clinical cardiac
symptoms after the BioNTech-Pfizer vaccine, which were not reported
before as one of the symptoms for non-vaccinated diagnosed COVID-19
pediatric and required more studies and health concerns.

Cardiac outcomes

COVID-19 patients are commonly diagnosed with acute cardiac injury (34).
Li et al. reported that 15\% to 44\% of COVID-19 patients had an
incidence of cardiac injury, which was significantly larger than the
prevalence found in congenital valvular disease (CVD) (5--15\%) (35).
This complied with a study published by Guo et al.(36), which revealed
that the risk of mortality from cardiac injury was substantially higher
than the risk of death from pre-existing CVD. Although it was common in
adults and elderly COVID-19 patients, no cases were reported for
COVID-19 pediatrics. Interestingly, our findings on pediatrics who had
the BioNTech-Pfizer vaccine showed that ST-segment elevation is the most
common cardiac symptoms in the ECG results. (14, 16-18). The authors
analyzed all vaccinated pediatric cardiac symptoms and revealed no
significant risk of mortality among patients (Table 3).

Troponin was also reported by Shi et al. as an independent risk factor
and a key biomarker for sign of death among COVID-19 patients (37). The
elevated troponin levels for vaccinated pediatrics were also measured.
It indicated an increased risk of cardiac injury in children who had the
BioNTech-Pfizer vaccine, but with no evidence of increased risk of
mortality.

Psychological outcomes

The prevalence of depression and anxiety in diagnosed COVID-19 patients
are documented and ranged from 22.6\% - 43.7\% and 18.9 \% - 37.4\%,
respectively (38-40). For instance, Xie et al. reported a survey on home
confinement among children during the COVID-19 pandemic. Authors found
that among 2330 students (1012 males), 403 students (22.6\%) reported
depression and anxiety symptoms (38). Across sectional study of 8079
participants was reported by Chen and co-workers among Chinese students
(12-18 years) during the COVID-19 pandemic to assess depressive and
anxiety symptoms. It revealed a prevalence of 43.7\%, 37.4\%, and 31.3\%
of depressive symptoms, anxiety symptoms, and a combination of
depressive and anxiety symptoms, respectively (39). Additionally, Liu et
al. published a report on psychological and behavioral changes among a
cluster of pneumonia patients, especially young people during the
COVID-19 pandemic. They found that patients had more state anxiety than
trait anxiety (15.8\% vs 4.0\%), 10.1\% suffered from phobia, and
depression was found among 27.1\% of respondents with 7.7\% had
psychological abnormalities(40). The prevalence of depression and
anxiety were also found in vaccinated children and adolescents with the
BioNTech-Pfizer vaccine. It showed the prevalence of 54.5\% and 11\% of
depression and anxiety among vaccinated children and adolescents,
respectively.

Strengths and Limitations

This review focused on vaccinated children and adolescents and provided
a comprehensive review and synthesis of the evidence on the
BioNTech-Pfizer vaccine's symptoms among children and adolescents.~There
are several limitations to this systematic review. To begin~with, the
included studies had low to intermediate methodological quality in terms
of their sampling method, measurement validity, and statistical
analysis.~These points~must be considered while evaluating the
results.~Secondly,~we omitted a few studies from our analyses due
to~the~lack of and/or ambiguous information. These studies reported
outcomes of the vaccine, however, did not differentiate between adult
and pediatric populations and the results could not be
extrapolated.~Nonetheless, despite these limitations, this is the first
review looking at the pediatric population exclusively. Furthermore, the
search and inclusion are a representation of the current published
literature and should be considered the most recent and up-to-date
evidence collectedly found.

\textbf{Conclusion}

Humankind and the entire world are still suffering from the third
coronavirus infection (SARS-CoV-2), causing severe acute respiratory
syndrome and bringing countless morbidity, mortality, and a great
economic disaster. With the new Delta andOmicron variants of this
coronavirus, more preventive measures and procedures, including more
vaccinations for children and adolescents, are crucial and highly
recommended to reduce the transmission, hospitalization, and adverse
clinical outcomes. Although we found good outcomes and statistically
significant associations in symptoms between vaccinated and
non-vaccinated pediatrics, more studies are still crucial to understand
the specific etiology further underlying post-vaccination, particularly
myocarditis, psychological impact, and other
cardiac~clinical~symptoms~on children and adolescents after receiving
the BioNTech-Pfizer vaccine.

\textbf{References:}

1. Adeyinka A, Bailey K, Pierre L, Kondamudi N. COVID 19 infection:
Pediatric perspectives. Journal of the American College of Emergency
Physicians Open. 2021;2(1):e12375.

2. Guarner J. Three Emerging Coronaviruses in Two Decades: The Story of
SARS, MERS, and Now COVID-19. American Journal of Clinical Pathology.
2020;153(4):420-1.

3. Hui DS, Azhar EI, Kim YJ, Memish ZA, Oh MD, Zumla A. Middle East
respiratory syndrome coronavirus: risk factors and determinants of
primary, household, and nosocomial transmission. Lancet Infect Dis.
2018;18(8):e217-e27.

4. Nashwan AJ, Villar RC, Al-Qudimat AR, Kader N, Alabdulla M, Abujaber
AA, et al. Quality of Life, Sleep Quality, Depression, Anxiety, Stress,
Eating Habits, and Social Bounds in Nurses during the Coronavirus
Disease 2019 Pandemic in Qatar (The PROTECTOR Study): A Cross-Sectional,
Comparative Study. J Pers Med. 2021;11(9).

5. Jaiswal V, Sarfraz Z, Sarfraz A, Mukherjee D, Batra N, Hitawala G, et
al. COVID-19 Infection and Myocarditis: A State-of-the-Art Systematic
Review. J Prim Care Community Health. 2021;12:21501327211056800.

6. Alwani M, Yassin A, Al-Zoubi RM, Aboumarzouk OM, Nettleship J, Kelly
D, et al. Sex-based differences in severity and mortality in COVID-19.
Rev Med Virol. 2021;31(6):e2223.

7. CDC. COVID-19 Cases, Deaths, and Trends in the US \textbar{} CDC
COVID Data Tracker. Centers for Disease Control and Prevention.
Published March 28, 2020. Accessed December 11, 2020.
https://covid.cdc.gov/ covid-data-tracker.

8. CDCMMWR. Coronavirus Disease 2019 in Children --- United States,
February 12--April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69. 10.
15585/mmwr.mm6914e4

9. Shekerdemian LS, Mahmood NR, Wolfe KK, Riggs BJ, Ross CE, McKiernan
CA, et al. Characteristics and Outcomes of Children With Coronavirus
Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric
Intensive Care Units. JAMA Pediatrics. 2020;174(9):868-73.

10. Zhang SF, Tuo JL, Huang XB, Zhu X, Zhang DM, Zhou K, et al.
Epidemiology characteristics of human coronaviruses in patients with
respiratory infection symptoms and phylogenetic analysis of HCoV-OC43
during 2010-2015 in Guangzhou. PLoS One. 2018;13(1):e0191789.

11. Tang P, Hasan MR, Chemaitelly H, Yassine HM, Benslimane FM, Al
Khatib HA, et al. BNT162b2 and mRNA-1273 COVID-19 vaccine effectiveness
against the SARS-CoV-2 Delta variant in Qatar. Nat Med. 2021.

12. Iheanacho CO, Eze UIH, Adida EA. A systematic review of
effectiveness of BNT162b2 mRNA and ChAdOx1 adenoviral vector COVID-19
vaccines in the general population. Bull Natl Res Cent. 2021;45(1):150.

13. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of
COVID-19 Among Children in China. Pediatrics. 2020;145(6).

14. 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(17):1663-5.

15. Parums DV. Editorial: First Full Regulatory Approval of a COVID-19
Vaccine, the BNT162b2 Pfizer-BioNTech Vaccine, and the Real-World
Implications for Public Health Policy. Med Sci Monit. 2021;27:e934625.

16. Wherry EJ, Jaffee EM, Warren N, D'Souza G, Ribas A. How Did We Get a
COVID-19 Vaccine in Less Than 1 Year? Clin Cancer Res.
2021;27(8):2136-8.

17. Ros-DeMarize R, Chung P, Stewart R. 2021. Pediatric behavioral
telehealth in the age of COVID-19: Brief evidence review and practice
considerations. \emph{Current Problems in Pediatric and Adolescent
Health Care} 51: 100949.

18. Lee MA. 2021. COVID pandemic as an incubator for a renewed vision of
pediatric value-based healthcare.\emph{Current Problems in Pediatric and
Adolescent Health Care} 51: 101064

19. Chokshi B, Pletcher BA, Strait JS. 2021. A trauma-informed approach
to the pediatric COVID-19 response.\emph{Current Problems in Pediatric
and Adolescent Health Care} 51: 100970

20. Verma S, Lumba R, Lighter JL, Bailey SM, Wachtel EV, Kunjumon B,
Alessi S, Mally PV. 2020. Neonatal intensive care unit preparedness for
the Novel Coronavirus Disease-2019 pandemic: A New York City hospital
perspective. \emph{Current Problems in Pediatric and Adolescent Health
Care} 50: 100795

21. Parums DV. Editorial: First Full Regulatory Approval of a COVID-19
Vaccine, the BNT162b2 Pfizer-BioNTech Vaccine, and the Real-World
Implications for Public Health Policy. Med Sci Monit. 2021;27:e934625-e.

22. Moher D, Liberati A, Tetzlaff J, Altman DG, The PG. Preferred
Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLOS Medicine. 2009;6(7):e1000097.

23. Marshall M, Ferguson ID, Lewis P, Jaggi P, Gagliardo C, Collins JS,
et al. Symptomatic Acute Myocarditis in 7 Adolescents After
Pfizer-BioNTech COVID-19 Vaccination. Pediatrics. 2021;148(3).

24. Moeller KE, Meeks M, Reynoldson J, Douglass M. Implementation and
Outcomes of COVID-19 Vaccinations at a Child and Adolescent Psychiatric
Hospital. J Am Acad Child Adolesc Psychiatry.
2021:S0890-8567(21)01362-9.

25. Tano E, San Martin S, Girgis S, Martinez-Fernandez Y, Sanchez Vegas
C. Perimyocarditis in Adolescents After Pfizer-BioNTech COVID-19
Vaccine. Journal of the Pediatric Infectious Diseases Society. 2021.

26. Schauer J, Buddhe S, Colyer J, Sagiv E, Law Y, Chikkabyrappa SM, et
al. Myopericarditis after the Pfizer mRNA COVID-19 Vaccine in
Adolescents. J Pediatr. 2021:S0022-3476(21)00665-X.

27. Dionne A, Sperotto F, Chamberlain S, Baker AL, Powell AJ, Prakash A,
et al. Association of Myocarditis With BNT162b2 Messenger RNA COVID-19
Vaccine in a Case Series of Children. JAMA Cardiol. 2021.

28. Hanna C, Herrera Hernandez LP, Bu L, Kizilbash S, Najera L, Rheault
MN, et al. IgA nephropathy presenting as macroscopic hematuria in 2
pediatric patients after receiving the Pfizer COVID-19 vaccine. Kidney
Int. 2021;100(3):705-6.

29. CDCMMWR. Long-Term Symptoms Among Adults Tested for SARS-CoV-2
-United States, January 2020--April 2021. MMWR / September 10, 2021 /
Vol. 70 / No. 36.

30. Mahase E. Covid-19: Pfizer reports 100\% vaccine efficacy in
children aged 12 to 15. BMJ. 2021;373:n881.

31. Goldstein E, Lipsitch M, Cevik M. On the Effect of Age on the
Transmission of SARS-CoV-2 in Households, Schools, and the Community. J
Infect Dis. 2021;223(3):362-9.

32. Ji LN, Chao S, Wang YJ, Li XJ, Mu XD, Lin MG, et al. Clinical
features of pediatric patients with COVID-19: a report of two family
cluster cases. World J Pediatr. 2020;16(3):267-70.

33. Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang Z-J. Novel Coronavirus
Infection in Hospitalized Infants Under 1 Year of Age in China. JAMA.
2020;323(13):1313-4.

34. Han Y, Zeng H, Jiang H, Yang Y, Yuan Z, Cheng X, et al. CSC Expert
Consensus on Principles of Clinical Management of Patients With Severe
Emergent Cardiovascular Diseases During the COVID-19 Epidemic.
Circulation. 2020;141(20):e810-e6.

35. Li X, Guan B, Su T, Liu W, Chen M, Bin Waleed K, et al. Impact of
cardiovascular disease and cardiac injury on in-hospital mortality in
patients with COVID-19: a systematic review and meta-analysis. Heart.
2020;106(15):1142-7.

36. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular
Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019
(COVID-19). JAMA Cardiol. 2020;5(7):811-8.

37. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of
Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in
Wuhan, China. JAMA Cardiol. 2020;5(7):802-10.

38. Xie X, Xue Q, Zhou Y, Zhu K, Liu Q, Zhang J, et al. Mental Health
Status Among Children in Home Confinement During the Coronavirus Disease
2019 Outbreak in Hubei Province, China. JAMA Pediatrics.
2020;174(9):898-900.

39. Zhou SJ, Zhang LG, Wang LL, Guo ZC, Wang JQ, Chen JC, et al.
Prevalence and socio-demographic correlates of psychological health
problems in Chinese adolescents during the outbreak of COVID-19. Eur
Child Adolesc Psychiatry. 2020;29(6):749-58.

40. Liu X, Luo WT, Li Y, Li CN, Hong ZS, Chen HL, et al. Psychological
status and behavior changes of the public during the COVID-19 epidemic
in China. Infect Dis Poverty. 2020;9(1):58.

\selectlanguage{english}
\FloatBarrier
\end{document}

