Coronavirus (COVID-19) in Children

As of April 2021, the COVID-19 pandemic is a year old and still not under control. COVID-19 is caused by SARS-CoV-2, a newly evolved respiratory virus that can progress to pneumonia, and in severe cases, to acute respiratory distress syndrome (ARDS) and death from respiratory and other organ system failure.

By the first week of April 2021, known global infections with COVID-19 had topped 127 million; the disease had occurred in nearly all countries throughout the world and caused about 2.8 million deaths.  The figures for the U.S. as of April 1, 2021 were more than 30 million cases, and about 550,000 deaths.¹ 

A summary of the CDC’s advice about what you need to know about COVID-19 among children and teens as follows:²

While fewer children have been sick with COVID-19 than adults, children can be infected with the virus that causes COVID-19, get sick from COVID-19, and spread the virus that causes COVID-19 to others even when they have no symptoms (“asymptomatic”).

Most children with COVID-19 have mild symptoms or have no symptoms at all. However, some children can get severely ill from COVID-19, require hospitalization, intensive care, or a ventilator to help them breathe. In rare cases, they may die. They may also get a rare but serious medical condition associated with COVID-19 in children called Multisystem Inflammatory Syndrome in Children (MIS-C).

Babies under one year old appear to be more likely to have a severe illness from COVID-19. Other children, regardless of age, with the following underlying medical conditions might also be at increased risk of severe illness compared to other children:

• Asthma or chronic lung disease
• Diabetes
• Genetic, neurologic, or metabolic conditions
• Sickle cell disease
• Heart disease since birth
• Immunosuppression (weakened immune system due to certain medical conditions or being on medications that weaken the immune system)
• Medical complexity (children with multiple chronic conditions that affect many parts of the body, or are dependent on technology and other significant supports for daily life)
• Obesity

Symptoms of COVID-19 are similar in adults and children and can look like symptoms of other common illnesses such as colds, strep throat, or allergies. The most common symptoms of COVID-19 in children are fever and cough, but children may have any of these signs or symptoms of COVID-19:

• Fever or chills
• Cough
• Nasal congestion or runny nose
• New loss of taste or smell
• Sore throat
• Shortness of breath or difficulty breathing
• Diarrhea
• Nausea or vomiting
• Stomachache
• Tiredness
• Headache
• Muscle or body aches
• Poor appetite or poor feeding, especially in babies under one year old

What parents can do
Monitor your child for COVID-19 symptoms. Pay particular attention to:

• Fever (temperature 100.4 °F or higher)
• Sore throat
• New uncontrolled cough that causes difficulty breathing (for a child with chronic allergic/asthmatic cough, see if there is a change from their usual cough)
• Diarrhea, vomiting, or stomachache
• New onset of severe headache, especially with a fever

Keep track of who your child comes into close contact with.
If your child or you were around someone who has COVID-19, someone from the health department might contact you for contact tracing. Speak with them and follow their advice.

Protect your child if you are sick and slow the spread of COVID-19.
Keep your child home and call their healthcare provider if your child gets sick.
If your child has symptoms of COVID-19:

• Keep your child home.
• Consider whether your child needs to see a healthcare provider and be tested for COVID-19. CDC recommends all people with symptoms of COVID-19, including children, get tested. CDC has a  available on its website, which may help you make decisions about seeking medical care for possible COVID-19.
• Protect yourself from COVID-19 while caring for your sick child by getting vaccinated against COVID-19, wearing a mask, washing your hands frequently, monitoring yourself for symptoms for COVID-19, and using other preventive measures.
• Notify your child's school that your child is sick. Also, inform the school if your child has had a COVID-19 test and what the result is, if available.
• Review your child’s school (or other childcare facility) policies related to when a child who has been sick can return.
• Bring your child back to school or other in-person activities only after they can safely be around others.

In a medical emergency, call 911 or bring your child to the emergency department.
Do not delay seeking emergency care for your child because you are worried about the spread of COVID-19. Emergency departments have infection prevention plans to protect you and your child from getting sick with COVID-19 if your child needs emergency care.

If your child is showing any of these emergency warning signs, seek emergency medical care immediately.

• Trouble breathing
• Pain or pressure in the chest that doesn’t go away
• New confusion
• Can’t wake up or stay awake when not tired
• Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone

This list does not include all possible symptoms.
Call your child’s healthcare provider for any other symptoms that are severe or concerning to you.

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COVID-19 disease characteristics

The nature of COVID-19, caused by the novel coronavirus SARS-CoV-2, made it especially likely to become a pandemic.  It is highly infective person to person either from airborne aerosols and droplets from a cough or, but less likely, from touching shed virus particles on surfaces where they might live up to a week. Another characteristic that heightens the risk of COVID-19 spread is the shedding of infectious virus particles during an incubation period of 2 to 14 days and during the several week-long course of the frequent inapparent or mild cases that occur. In contrast, SARS-CoV (the coronavirus that causes severe acute respiratory syndrome, or SARS) was more easily dealt with because it was not highly transmissible until an individual had symptoms. Community spread of COVID-19, that is without contact with known infected individuals, is occurring.

Information so far suggests that many COVID-19 infections are inapparent or cause only mild illness. A report from China in the New England Journal of Medicine suggests serious illness, principally viral pneumonia, occurs in 16% of cases.³  Of about 1000 patients seen at Chinese hospitals, 5.0% were admitted to the intensive care unit (ICU), 2.3% needed mechanical ventilation for acute respiratory distress, and 1.4% died from respiratory failure.  Other data and data from China suggest that the death rate among symptomatic patients increases markedly with the age of the patient.  The death rate among those age 80 or older may reach 15%. 

Although it is known that COVID-19 can cause severe disease among persons of all ages, if there is any good news for children and youth, it is that COVID-19 infection in children is usually mild compared to the course of the disease in older people.  Of the first 70,000 patients in China diagnosed with COVID-19, only 2.1% were children under 19.  Only one child age 10-19 years died, and no children under the age of 9 died.⁴

Another study in China found that 90% of children had mild to moderate symptoms.  Among symptomatic children, 5% had shortness of breath or low blood oxygen, and 0.6% progressed to ARDS or organ system dysfunction, a rate lower than that seen in adults.⁵  Preschool-aged children and infants were more likely to have severe symptoms than older children.

A review of studies available in early 2020 found that almost all COVID-19 cases in children were asymptomatic or were quite mild.⁶  Children at any age were mostly reported to have mild respiratory symptoms, namely fever, dry cough, fatigue, or asymptomatic.  Among the articles reviewed, there was only 1 case of severe COVID-19 infection, which occurred in a 13-month-old infant. No deaths were reported in children aged 0 to 9 years.
 
Preliminary U.S. data from February 12, 2020 to March 16, 2020 indicates that among a small group of COVID-19 patients with known outcomes, 1.6% to 2.4% of children up to age 19 were hospitalized, and no deaths occurred.⁷  The fatality rate was <1% among persons aged 20–54 years, and fatalities were highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, and 1% to 3% among persons aged 55-64 years. 

Updated data from the CDC covering February 12, 2020 to April 2, 2020 described 2572 COVID-19 cases in children out of nearly 150,000 coronavirus cases in the U.S.⁸  Pediatric cases represented 1.7% of reported cases, whereas 22% of the U.S. population is made up of infants, children, and adolescents aged <18 years.  Fewer children (73%) than adults (93%) experience the symptoms of fever, cough, or shortness of breath.  Of those children with known hospitalization status, 5.7% of all patients were hospitalized,  compared to 10% of adults aged 18–64 years. Among children with COVID-19 who were reported to be hospitalized, 0.58%–2.0% were admitted to an ICU. Three deaths were reported among the pediatric cases. 

A brief report in May 2020 about COVID-19 infections among children in Italy found that according to the categories described by the Chinese studies, 21% of the patients were asymptomatic, 58% had mild disease, 19% had moderate disease, 1% had severe disease, and 1% were in critical condition.

Since March 2020, when most U.S. schools conducted classes virtually or were closed for the summer, the incidence of COVID-19 among adolescents was approximately double that in younger children. Although mortality and hospitalization in school-aged children were low, Hispanic ethnicity, Black race, and underlying conditions were more commonly reported among children hospitalized or admitted to an ICU, providing additional evidence that some children might be at increased risk for severe illness associated with COVID-19.⁹ Acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have been reported to disproportionately affect Hispanic and Black children.

CDC reported data on illness caused by COVID-19 in children for the period March 1, 2020 to September 19, 2020 is shown in the table below.

Age group                         5–11 yrs (n = 101,503)    12–17 yrs (n = 175,782)

Underlying conditions were more common among school-aged children with severe outcomes related to COVID-19. Chronic lung disease, including asthma, was most commonly reported (7%), followed by disability (1%), immunosuppressive conditions (0.9%), diabetes (0.8%), psychological conditions (0.7%), cardiovascular disease (0.6%), and severe obesity (0.5%). At least one underlying condition was reported for 23% of school-aged children who were hospitalized for COVID-19, 38% of those admitted to an ICU, and 33% of those who died.¹⁰

Although children seem to be relatively spared from symptomatic COVID-19 disease, the condition in infants can be severe.  Preliminary data suggest that pregnant women with COVID-19 infections transmit anti-COVID-19 antibodies to their fetuses, but it is not known if that will protect them from the disease.¹¹

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Prevention

The following measures to curtail the spread of COVID-19 and protect children and others from getting sick are based on CDC recommendations.¹²

Immunization

As of the date of this report, April 1, 2021, vaccination against COVID-19 is rapidly becoming available for all U.S. adults. The Moderna and Johnson & Johnson vaccines are cleared for people 18 and older, and the Pfizer vaccine is authorized for ages 16 and up. Moderna and Pfizer have completed enrollment for studies of children ages 12 and older and expect to release the data over the summer, so immunization of children is likely to become available soon.

Prevention of COVID-19 infection with immunization is probably the most important long-term solution to curtailing the coronavirus epidemic for both children and adults.  Although currently approved vaccines appear to be highly effective, with up to 95% reduction of risk of disease of any severity and 100% prevention of hospitalization and death, the duration of protection has not been established, and the evolution of new, more infectious and possibly more lethal variants of the SARS-CoV-2 virus is occurring.  Therefore the degree of long-term protection provided by vaccination is not certain.

Social distancing

Among the most important ways to prevent getting COVID-19 is "social distancing," or better defined as physical separation from those who may be sick with COVID-19. If school is out, children should not have in-person playdates with children from other households. If children are playing or in any public place outside their own homes, they as well as adults should remain 6 feet from anyone who is not in their own household.

CDC has updated its advice about physical distancing in elementary schools. CDC recommends all students remain at least 3 feet apart in classrooms where mask use is universal — regardless of whether community transmission is low, moderate, substantial, or high.

You and your children should clean your hands often.

• Wash your hands often with soap and water for at least 20 seconds, especially after you have been in a public place or after blowing your nose, coughing, or sneezing.
• If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
• Avoid touching your eyes, nose, and mouth with unwashed hands.

Cover your mouth and nose with a cloth face cover or mask when near other people.

• You could spread COVID-19 to others even if you do not feel sick.
• Everyone should wear a cloth face cover when they have to go out in public, for example, to the grocery store or to pick up other necessities.
• Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
• A cloth face cover provides some protection to you and protects other people if you are infected.
• Continue to keep about 6 feet between yourself and others. The cloth face cover is not a substitute for social distancing.
• Do not touch your cloth face mask and wash it in soap and hot water after being in public places.
• Use a face mask if you are caring for a sick child or adult or cleaning up blood, stool or body fluid such as saliva, sputum, nasal mucus, vomit, urine.

Cover coughs and sneezes

• If you are in a private setting and do not have on your cloth face covering, remember to always cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.
• Throw used tissues in the trash.
• Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.

• Clean and disinfect frequently touched surfaces daily. This includes tables, remotes, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
• If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection.
• Launder items, including washable plush toys as needed. Follow the manufacturer's instructions. If possible, launder items using the warmest appropriate water setting and dry items completely. Dirty laundry from an ill person can be washed with other people's items.
• To disinfect: Most common EPA-registered household disinfectants will work. Visit https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-againstsars-cov-2 to find the current list of products that meet EPA’s criteria for use against SARS-CoV-2, the cause of COVID-19. These Products are expected to be effective against COVID-19 based on data for harder to kill viruses. . Use disinfectants appropriate for the surface and follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.). When using Alcohol solutions, ensure that the solution has at least 70% alcohol.

Keep children mentally healthy

Watch for signs of stress in your child

Some common changes to watch for include excessive worry or sadness, unhealthy eating or sleeping habits, and difficulty with attention and concentration. For more information, see the “For Parents” section of CDC’s Stress and Coping.

• Take time to talk with your child or teen about the COVID-19 outbreak. Answer questions and share facts about COVID-19 in a way that your child or teen can understand.
• Go to CDC’s Helping Children Cope with Emergencies or Talking with Children About COVID-19 for more information.

Teach and reinforce everyday preventive actions

• Parents and caretakers play an important role in teaching children to wash their hands. Explain that handwashing can keep them healthy and stop the virus from spreading to others.
• Be a good role model—if you wash your hands often, they’re more likely to do the same.
• Make handwashing a family activity.
• Learn more about handwashing and other everyday preventive actions.

Help your child stay active

• Encourage your child to play outdoors—it’s great for physical and mental health. Take a walk with your child or go on a bike ride.
• Use indoor activity breaks (like stretch breaks or dance breaks) throughout the day to help your child stay healthy and focused.

Help your child stay socially connected

• Reach out to friends and family via phone or video chats.
• Write cards or letters to family members they may not be able to visit.
• Some schools and non-profits have resources for social and emotional learning. Check to see if your school has tips and guidelines to help support the social and emotional needs of your child.

Ask about school meal services
Check with your school on plans to continue meal services during the school dismissal. Many schools keep school facilities open to allow families to pick up meals or provide grab-and-go meals at a central location.

Help children continue learning

• Stay in touch with your child's school.
• Many schools are offering lessons online (virtual learning). Review assignments from the school, and help your child establish a reasonable pace for completing the work. You may need to assist your child with turning on devices, reading instructions, and typing answers.
• Communicate challenges to your school. If you face technology or connectivity issues, or if your child is having a hard time completing assignments, let the school know.

Create a flexible schedule and routine for learning at home

• Have consistent bedtimes and get up at the same time, Monday through Friday.
• Structure the day for learning, free time, healthy meals and snacks, and physical activity.
• Allow flexibility in the schedule—it’s okay to adapt based on your day.

Consider the needs and adjustment required for your child’s age group

• The transition to being at home will be different for preschoolers, K-5, middle school students, and high school students. Talk to your child about expectations and how they are adjusting to being at home versus at school.
• Consider ways your child can stay connected with their friends without spending time in person.

Look for ways to make learning fun

• Have hands-on activities, like puzzles, painting, drawing, and making things.
• Independent play can also be used in place of structured learning. Encourage children to build a fort from sheets or practice counting by stacking blocks.
• Practice handwriting and grammar by writing letters to family members. This is a great way to connect and limit face-to-face contact.
• Start a journal with your child to document this time and discuss the shared experience.
• Use audiobooks or see if your local library is hosting virtual or live-streamed reading events.

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Predicting the course of COVID-19

Prevention of COVID-19 infection with immunization of adults is now possible and probably the most important long-term solution to curtailing the coronavirus epidemic for both children and adults. Widespread immunization and infection may lead to “herd immunity," where there are relatively few people remaining at risk of getting infected, and the virus dies out. However, because COVID-19 is not being well controlled in other countries, a reservoir for the virus is likely to persist. For those who get sick, current treatment is mainly s supportive, including administration of oxygen and use of ventilators for severe pneumonia. A variety of existing and experimental antiviral drugs and antibodies are being studied as a treatment for COVID-19. It may turn out that some existing antiviral drugs are effective, and new highly effective ones may be developed.

When testing becomes more widely available, it may become possible to partially control the epidemic by containment––the identification, isolation, and care for cases and identification, immunization, and if needed, the isolation and care for their contacts. This is the usual way public health measures have successfully halted other epidemics.

A lesson from the COVID-19 pandemic emphasizes the importance of investing in robust public health systems, research into animal and human pathogens, and preparedness for medical care providers and systems. This must include addressing the animal reservoirs of infectious agents that may infect humans.

Endnotes

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