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:
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:
What parents can do
Keep track of who your child comes into close contact with.
Protect your child if you are sick and slow the spread of COVID-19.
In a medical emergency, call 911 or bring your child to the emergency department.
If your child is showing any of these emergency warning signs, seek emergency medical care immediately.
This list does not include all possible symptoms.
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.
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.
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
The following measures to curtail the spread of COVID-19 and protect children and others from getting sick are based on CDC recommendations.12
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.
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.
Cover your mouth and nose with a cloth face cover or mask when near other people.
Cover coughs and sneezes
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.
Teach and reinforce everyday preventive actions
Help your child stay active
Help your child stay socially connected
Ask about school meal services
Help children continue learning
Create a flexible schedule and routine for learning at home
Consider the needs and adjustment required for your child’s age group
Look for ways to make learning fun
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.
1 Coronavirus data center. Johns Hopkins University. April 1, 2021. https://coronavirus.jhu.edu/map.html
2 COVID-19 in Children and Teens Information for parents and caregivers about COVID-19 in children and teens. CDC March 17, 2021
3 Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. February 28, 2020. DOI: 10.1056/NEJMoa2002032.
4 The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122.
5Dong Y, Mo X, Hu, Y, et al. [Epidemiology of COVID-19 among children in China]. IN PRESS this issue Pediatrics. March 16, 2020
6 Castagnoli R, Votto M, Licari A, et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA Pediatr. Published online April 22, 2020. doi:10.1001/jamapediatrics.2020.1467
7 Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:343-346. DOI: http://dx.doi.org/10.15585/mmwr.mm6912e2external icon
9 Leeb RT, Price S, Sliwa S, et al. COVID-19 Trends Among School-Aged Children — United States, March 1–September 19, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1410–1415. DOI: http://dx.doi.org/10.15585/mmwr.mm6939e2external icon
10 Leeb RT, Price S, Sliwa S, et al. COVID-19 Trends Among School-Aged Children — United States, March 1–September 19, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1410–1415. DOI: http://dx.doi.org/10.15585/mmwr.mm6939e2external icon
11 Zeng H, Xu C, Fan J, et al. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA. Published online March 26, 2020. doi:10.1001/jama.2020.4861
12 Coronavirus disease (Covid_19), How to protect yourself and others. Centers for Disease Control and Prevention. April 4, 2020. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html