Incidence of COVID-19 in Children
In the United States and globally, fewer cases of COVID-19 have been reported in children (age 0-17 years) compared with adults.1,2 While children comprise 22% of the U.S. population,3 the most recent data, available through the CDC, show that some cases of COVID-19 in the United States reported to CDC were among children.4 The number and rate of cases in children in the United States have been steadily increasing since March 2020. The true incidence of SARS-CoV-2 infection in children is not known due to lack of widespread testing and the prioritization of testing for adults and those with severe illness. Hospitalization rates in children are significantly lower than hospitalization rates in adults with COVID-19, suggesting that children may have less severe illness from COVID-19 compared to adults.5,6 Visit CDC’s COVID Data Tracker page for current data.
Infections and Transmission Among Children
Recent evidence suggests that compared to adults, children likely have similar viral loads in their nasopharynx,7 similar secondary infections rates, and can spread the virus to others.8,9
Due to community mitigation measures and school closures, transmission of SARS-CoV-2 to and among children may have been reduced in the United States during the pandemic in the spring and early summer of 2020. This may explain the low incidence in children compared with adults. Comparing trends in pediatric infections before and after the return to child care, in-person school, youth sports and other activities may enhance our understanding about infections in children.
The incubation period of SARS-CoV-2 appears to be about the same for children as in adults, at 2-14 days with an average of 6 days.10
Signs or symptoms of COVID-19 in children include:
- Nasal congestion or rhinorrhea
- New loss of taste or smell
- Sore throat
- Shortness of breath or difficulty breathing
- Abdominal pain
- Nausea or vomiting
- Poor appetite or poor feeding
Children infected with SARS-CoV-2 may have many of these non-specific symptoms, only have a few (such as only upper respiratory symptoms or only gastrointestinal symptoms), or may be asymptomatic. The most common symptoms in children are cough and/or fever.11-15 A recent systematic review estimated that 16% of children with SARS-CoV-2 infection are asymptomatic,16 but evidence suggests that as many as half of pediatric infections may be asymptomatic.17 The signs and symptoms of COVID-19 in children are similar to those of other infections and noninfectious processes, including influenza, streptococcal pharyngitis, and allergic rhinitis. The lack of specificity of signs or symptoms and the significant proportion of asymptomatic infections make symptom-based screening for identification of SARS-CoV-2 in children particularly challenging.17
Severity of Illness in Children
While children infected with SARS-CoV-2 are less likely to develop severe illness compared with adults, children are still at risk of developing severe illness and complications from COVID-19. Weekly COVID-19 hospitalization surveillance data show that the rate of hospitalization among children is low compared with that of adults, but hospitalization rates among children are increasing.18 About 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit, similar to the rate among adults.19,20
Current evidence suggests that children with certain underlying medical conditions and infants (age <1 year) might be at increased risk for severe illness from SARS-CoV-2 infection.11,14 Of the children who have developed severe illness from COVID-19, most have had underlying medical conditions.19
- There is limited evidence about which underlying medical conditions in children might increase the risk for severe illness. Current evidence suggests that children with medical complexity, with genetic, neurologic, metabolic conditions, or with congenital heart disease might be at increased risk for severe illness from COVID-19. Similar to adults, children with obesity, diabetes, asthma or chronic lung disease, sickle cell disease, or immunosuppression might also be at increased risk for severe illness from COVID-19.
- While healthcare providers should maintain a high index of suspicion for SARS-CoV-2 infection in these populations and monitor the progression of illness closely, it appears that most infants21 and children with certain underlying conditions such as cancer22 who are infected with SARS-CoV-2 do not usually develop severe COVID-19 illness.
- Hospitalization rates in the United States are higher among Hispanic/Latino children and non-Hispanic Black children compared with non-Hispanic White children. Studies of hospitalized children have found that obesity was the most prevalent underlying condition.19 Additional studies are needed to identify the association between SARS-CoV-2 infection and obesity to find possible clinical interventions and strategies to reduce hospitalization risk.19
Similar to adults, children with severe COVID-19 may develop respiratory failure, myocarditis, shock, acute renal failure, coagulopathy, and multi-organ system failure. Some children with COVID-19 have developed other serious problems like intussusception or diabetic ketoacidosis.14,2,23 Children infected with SARS-CoV-2 are also at risk for developing Multisystem Inflammatory Syndrome in Children (MIS-C).24 For the case definition, recommended evaluation, and current data on MIS-C cases in the United States, visit MIS-C Information for Healthcare Providers.
Viral tests (nucleic acid or antigen) are recommended to diagnose acute infection with SARS-CoV-2. Testing strategies, including clinical criteria for considering testing and recommended specimen type, are the same for children and adults. CDC’s guidance for the evaluation and management of neonates at risk for COVID-19 details specific testing considerations for newborns.
For more information on CDC’s recommendations for isolation, which apply to children and adults, visit: discontinuing precautions and disposition of patients with COVID-19 in healthcare settings and discontinuation of isolation for people not in healthcare settings.
Testing, Isolation, and Quarantine for School-Aged Children
Pediatric healthcare providers should be prepared to answer questions from families about testing and when it is safe for children who have had, or were exposed to, COVID-19 to return to school or be with people outside the household. Review CDC’s information for school administrators on symptom screening and testing for children in school as well as CDC’s Community Mitigation Framework.
School-aged children should be prioritized for viral testing if they have:
- Signs or symptoms of COVID-19 and
- close contact (within 6 feet of someone for a total of 15 minutes or more) with a person with laboratory-confirmed or probable SARS-CoV-2 infection or
- increased likelihood for exposure (which includes living in or traveling to a community with substantial transmission as defined by the local public health department and described in CDC’s Community Mitigation Framework)
- No symptoms but have had close contact (within 6 feet of someone for a total of 15 minutes or more) with a person with laboratory-confirmed or probable SARS-CoV-2 infection.
Children with symptoms of an infectious disease should not attend school, but the length of time the child should stay home depends on the most likely etiology of illness (COVID-19 or not). Return to school policies for children with COVID-19 should be based on CDC’s recommendation for discontinuation of home isolation. A negative test or doctor’s note should not be required for return to school upon completion of the 10 days of isolation with improvement of symptoms.
- If the child has symptoms of COVID-19, but the child has not had close contact (within 6 feet of someone for a total of 15 minutes or more) with a person with laboratory-confirmed or probable SARS-CoV-2 infection and the child does not have an increased likelihood for exposure to SARS-CoV-2 (which includes living in or traveling to a community with substantial transmission), he or she should be evaluated for other disease processes. If the child is determined to likely not have COVID-19 by a healthcare provider, he/she should be allowed to return to school according to existing school policies for non-COVID-19 illnesses. Examples of non-COVID-19 return to school policies include resolution of fever without antipyretics for 24 hours for non-COVID-19 viral illnesses or after initiation of antibiotics for bacterial illnesses.
- If the child has symptoms of COVID-19 and has increased likelihood for exposure (which includes living in or traveling to a community with substantial transmission), he or she should be tested for SARS-CoV-2 infection, if possible. If the test result is negative, the child should be allowed to return to school once their symptoms of illness have improved consistent with non-COVID return to school policies. If testing cannot be obtained, the child should be considered a presumed case of COVID-19 and should isolate according to CDC’s recommendations for discontinuation of home isolation.
- If the child has had close contact to someone with SARS-CoV-2, he or she should be tested for SARS-CoV-2. Please use CDC’s COVID-19: When to Quarantine when providing guidance.
Typical laboratory findings in children with COVID-19 include mild abnormalities in white blood cell count (either increased or decreased lymphocyte counts), mildly elevated inflammatory markers (including procalcitonin), and mildly elevated liver enzymes.25 Radiologic findings in children with COVID-19 include unilateral or bilateral infiltrates on chest radiograph or CT, ground-glass opacities on CT, and consolidation with surrounding Halo sign on CT.25,26 CT should be used sparingly and only for hospitalized, symptomatic patients with specific clinical indications. For more information, see recommendations from the American College of Radiologyexternal icon.
Pediatric healthcare providers should consider the child’s clinical presentation, requirement for supportive care, underlying medical conditions, and the ability for caregivers to care for the child at home when deciding whether the child may need inpatient care for COVID-19. For more information, visit Guidance for home care of people not requiring hospitalization for Coronavirus Disease 2019 (COVID-19). Provide parents resources on emergency warning signs for COVID-19 and caring for someone at home.
Currently, there are no drugs specifically approved by the U.S. Food and Drug Administration (FDA) for treatment of COVID-19 in children. Treatment of COVID-19 remains largely supportive and includes prevention and management of complications. Remdesivirexternal icon, which has shown benefits in clinical trials in adults, is currently available through Emergency Use Authorization or compassionate use programs for children. The safety and effectiveness of remdesivir for treatment of COVID-19 has not yet been evaluated in children. Additionally, the National Institutes of Health (NIH) suggests that dexamethasoneexternal icon may be beneficial in pediatric patients with COVID-19 respiratory disease who are on mechanical ventilation. For more information, review considerations for childrenexternal icon in NIH’s COVID-19 Treatment Guidelines.27
For information on evaluation and management of MIS-C, visit MIS-C Information for Healthcare Providers.
It is important to remember that children infected with SARS-CoV-2 can present with other serious conditions such as diabetic ketoacidosis or intussusception, and a broad differential must be maintained in evaluating ill children during the COVID-19 pandemic.14,2,23,28-30 Standard evaluation and management of co-occurring conditions should be maintained for a child infected with SARS-CoV-2, with additional infection control measures. Pediatric providers should have an appropriate suspicion for COVID-19, but also to continue to consider and test for other diagnoses, such as community acquired pneumoniaexternal icon, influenza (see CDC’s Flu Information for Healthcare Professionals for more information) and strep pharyngitispdf icon.
CDC has specific guidance for inpatient obstetric healthcare settings and the evaluation and management of neonates at risk for COVID-19. Additionally, several other organizations have published guidelines related to the treatment and management of adult and pediatric patients with COVID-19:
Community mitigation measures such as shelter-in-place orders resulted in declines in outpatient pediatric visits and fewer vaccine doses administered during the early COVID-19 pandemic,31 leaving children at risk for vaccine-preventable diseases. Healthcare providers should work with families to keep children up-to-date with all recommended vaccinations, especially with influenza vaccinations for the 2020-2021 influenza season. For more information on influenza, visit CDC’s Influenza page. For more information on immunization services and vaccination recommendations during the pandemic, visit Vaccination Guidance.
Healthcare providers should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule in-person appointments, with prioritization of infants, children age < 24 months and school-aged children. Developmental surveillance and early childhood screenings, including developmental and autism screening, should continue along with referrals for early intervention services and further evaluation if concerns are identified.
All newborns should be seen by a pediatric healthcare provider shortly after hospital discharge (three to five days of age). Ideally, newborn visits should be done in-person, even during the COVID-19 pandemic, to evaluate feeding and weight gain, check for dehydration and jaundice, ensure all components of newborn screening were completed with appropriate confirmatory testing and follow-up, and evaluate maternal well-being. All healthcare facilities should ensure infection prevention and control policies are in place to minimize chance of exposure to SARS-CoV-2 among providers, patients, and families. For specific recommendations by healthcare facility type and level of community transmission, review Infection Control Guidance for Healthcare Professionals. CDC has additional trainings and information about potential exposures in the workplace for healthcare providers.
Pediatric healthcare providers should incorporate education on everyday infection prevention measures, such as the importance of proper hand hygiene, social distancing, and wearing masks when in public, as well as information on stress and coping during the pandemic in their regular anticipatory guidance with children and their families. Pediatric healthcare providers should educate patients and families about infection prevention policies that exist in emergency departments, hospitals, and clinics. Remind people to seek emergency care immediately, if indicated, as delaying care may cause harm.
Primary care practices should continue to use infection prevention strategies including:
- Scheduling sick visits and well-child visits during different times of the day
- Reducing crowding in waiting rooms, by asking patients to remain outside (e.g., stay in their vehicles, if applicable) until they are called into the facility for their appointment, or setting up triage booths to screen patients safely
- Considering telemedicine for visits that do not involve vaccination or do not require an in-person physical exam. For more information, visit Using Telehealth Services
- Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance — United States, January 22–May 30, 2020. MMWR. 2020;69:759–765. doi:10.15585/mmwr.mm6924e2.
- Williams N, Radia T, Harman K, et al. COVID-19 Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review of Critically Unwell Children and the Association With Underlying Comorbidities. Eur J Pediatr. 2020;10:1-9. doi:10.1007/s00431-020-03801-6external icon.
- U.S. Census Bureau. Quick Facts United States. Available at: https://www.census.gov/quickfacts/fact/table/US/AGE295219#AGE295219external icon.
- Centers for Disease Control and Prevention. Demographic Trends of COVID-19 cases and deaths in the US reported to CDC. Available at: https://www.cdc.gov/covid-data-tracker/index.html#demographics.
- Bixler D, Miller AD, Mattison CP, et al. SARS-CoV-2–Associated Deaths Among Persons Aged <21 Years — United States, February 12–July 31, 2020. MMWR. 2020;69:1324–1329. doi:10.15585/mmwr.mm6937e4.
- Leeb RT, Price S, Sliwa S, et al. COVID-19 Trends Among School-Aged Children — United States, March 1–September 19, 2020. MMWR. 2020;69:1410–1415. doi:10.15585/mmwr.mm6939e2external icon.
- Sargent TH, Muller WJ, Zheng X, et al. Age-Related Differences in Nasopharyngeal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Levels in Patients With Mild to Moderate Coronavirus Disease 2019 (COVID-19). JAMA Pediatrics. 2020;174(9):902-903. doi:10.1001/jamapediatrics.2020.3651external icon.
- Yonker LM, Neilan AM, Bartsch Y, et al. Pediatric Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): Clinical Presentation, Infectivity, and Immune Responses. J Pediatr. 2020;227:45-52.e5. doi:10.1016/j.jpeds.2020.08.037external icon.
- Laws RL, Chancey RJ, Rabold EM, et al. Symptoms and Transmission of SARS-CoV-2 Among Children — Utah and Wisconsin, March–May 2020. Pediatrics. 2020;146(6):e2020027268. doi:10.1542/peds.2020-027268external icon.
- Centers for Disease Control and Prevention. COVID-19 Pandemic Planning Scenarios. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html#table-2.
- Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics. 2020;145(6):e20200702. doi:10.1542/peds.2020-0702external icon.
- Götzinger F, Santiago-García B, Noguera-Julián A, et al. COVID-19 in Children and Adolescents in Europe: A Multinational, Multicentre Cohort Study. Lancet Child Adolesc Health. 2020;4(9):653-661. doi:10.1016/S2352-4642(20)30177-2external icon.
- Teherani MF, Kao CM, Camacho-Gonzalez A, et al. Burden of Illness in Households With Severe Acute Respiratory Syndrome Coronavirus 2–Infected Children. J Pediatric Infect Dis Soc. 2020;9(5):613–616. doi:10.1093/jpids/piaa097external icon.
- Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. 2020;174(9):868-873. doi:10.1001/jamapediatrics.2020.1948external icon.
- Mannheim J, Gretsch S, Layden JE, Fricchione MJ. Characteristics of Hospitalized Pediatric Coronavirus Disease 2019 Cases in Chicago, Illinois, March-April 2020. J Pediatric Infect Dis Soc. 2020;9(5):519-522. doi:10.1093/jpids/piaa070external icon.
- Assaker R, Colas A-E, Julien-Marsollier F, et al. Presenting Symptoms of COVID-19 in Children: A Meta-Analysis of Published Studies. Br J Anaesth. 2020;125(3):e330-e332. doi:10.1016/j.bja.2020.05.026external icon.
- Poline J, Gaschignard J, Leblanc C, et al. Systematic Severe Acute Respiratory Syndrome Coronavirus 2 Screening at Hospital Admission in Children: A French Prospective Multicenter Study. Clin Infect Dis. 2020;ciaa1044. doi:10.1093/cid/ciaa1044external icon.
- Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET). Available at: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covid-net/purpose-methods.html.
- Kim L, Whitaker M, O’Halloran A, et al. Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 – COVID-NET, 14 States, March 1-July 25, 2020. MMWR. 2020;69(32):1081-1088. doi:10.15585/mmwr.mm6932e3external icon.
- Kim L, Garg S, O’Halloran A, et al. Risk Factors for Intensive Care Unit Admission and In-hospital Mortality among Hospitalized Adults Identified through the U.S. Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET). Clin Infect Dis. 2020;ciaa1012. doi:10.1093/cid/ciaa1012external icon.
- Maltezou HC, Magaziotou I, Dedoukou X, et al. Children and Adolescents With SARS-CoV-2 Infection: Epidemiology, Clinical Course and Viral Loads. Pediatr Infect Dis J. 2020;39(12):e388-e392. doi:10.1097/INF.0000000000002899external icon.
- Boulad F, Kamboj M, Bouvier N, et al. COVID-19 in Children With Cancer in New York City. JAMA Oncol. 2020;6(9):1459-1460. doi:10.1001/jamaoncol.2020.2028external icon.
- Fernandes DM, Oliveira CR, Guerguis S, et al. Severe Acute Respiratory Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth. J Pediatr. 2020;S0022-3476(20)31393-7. doi:10.1016/j.jpeds.2020.11.016external icon.
- Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. N Engl J Med. 2020;383(4):334-346. doi:10.1056/NEJMoa2021680external icon.
- Zimmermann P, Curtis N. COVID-19 in Children, Pregnancy, and Neonates: A Review of Epidemiologic and Clinical Features. Pediatr Infect Dis J. 2020;39(6):469-477. doi: 10.1097/INF.0000000000002700external icon.
- Xia W, Shao J, Guo Y, et al. Clinical and CT Features in Pediatric Patients With COVID-19 Infection: Different Points from Adults. Pediatr Pulmonol. 2020;55(5):1169-1174. doi: 10.1002/ppul.24718external icon.
- National Institutes of Health. COVID-19 Treatment Guidelines: Special Considerations in Children. Available at: https://www.covid19treatmentguidelines.nih.gov/special-populations/children/external icon.
- Lin EE, Blumberg TJ, Adler AC, et al. Incidence of COVID-19 in Pediatric Surgical Patients Among 3 US Children’s Hospitals. JAMA Surg. 2020;155(8):775-777. doi:10.1001/jamasurg.2020.2588external icon.
- Cai X, Ma Y, Li S, et al. Clinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children. Front Pediatr. 2020;8:258. doi:10.3389/fped.2020.00258external icon.
- Lui K, Wilson MP, Low G. Abdominal Imaging Findings in Patients With SARS-CoV-2 Infection: A Scoping Review. Abdom Radiol (NY). 2020;1-7. doi:10.1007/s00261-020-02739-5external icon.
- Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration – United States, 2020. MMWR. 2020;69:591-593. doi:10.15585/mmwr.mm6919e2.