Coronavirus Disease 2019 (COVID-19) in Children 

Updated: May 11, 2020
  • Author: Bayan Issa, MD; Chief Editor: David J Cennimo, MD, FAAP, FACP, AAHIVS  more...
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Practice Essentials

Coronavirus disease 2019 (COVID-19) is an illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Relatively few cases have been seen in children thus far; in China, only about 2.4% occurred in those under 19 years of age. [1]  Similar trends have been observed in the United States. [2]  Most cases in children are mild, and treatment consists of supportive care. With the exception of the antiviral remdesivir, no drugs or biologics have been proven to be effective for the prevention or treatment of COVID-19, and no vaccine is currently available. [3, 4, 5]

Signs and symptoms of COVID-19 in children

Common symptoms of COVID-19 in children are cough and fever. It is important to note, however, that these symptoms may not always be present; thus, a high index of suspicion for SARS-CoV-2 infection is required in children. [2, 6, 7]  Other symptoms include the following:

  • Shortness of breath
  • Pharyngeal erythema/sore throat
  • Diarrhea
  • Myalgia
  • Fatigue
  • Rhinorrhea
  • Vomiting
  • Nasal congestion
  • Abdominal pain
  • Conjunctivitis
  • Rash

Diagnosis

Laboratory studies

Although a consistent pattern of characteristic laboratory findings has not yet been identified in children with confirmed COVID-19, the following abnormalities have been observed:

  • Lymphopenia
  • Increased levels of liver and muscle enzymes and lactate dehydrogenase
  • Increased myoglobin and creatine kinase isoenzyme levels
  • Elevated C-reactive protein (CRP) level
  • Elevated erythrocyte sedimentation rate
  • Increased procalcitonin level

Imaging studies

Common chest radiograph findings in children with COVID-19 pneumonia include bilaterally distributed peripheral and subpleural ground-glass opacities and consolidation. [8]

Findings observed on computed tomography (CT) of the chest in children with COVID-19 include the following:

  • Ground-glass opacities/nodules
  • Consolidation with a surrounding halo sign
  • Bilateral or local patchy shadowing
  • Interstitial abnormalities

Management

Treatment consists of supportive care, including oxygen therapy in children with hypoxia. 

With the exception of the antiviral remdesivir, no drugs or biologics have been proven to be effective for the prevention or treatment of COVID-19. Remdesivir gained emergency use authorization (EUA) from the US Food and Drug Administration (FDA) on May 1, 2020, based on preliminary data showing a faster time to recovery of hospitalized patients with severe disease. [3, 4, 5]  Numerous other antiviral agents, immunotherapies, and vaccines continue to be investigated and developed as potential therapies.

Please see Coronavirus Disease 2019 (COVID-19) for continually updated clinical guidance concerning COVID-19 and Treatment of Coronavirus Disease 2019 (COVID-19): Investigational Drugs and Other Therapies for updated drug information. Health care personnel are also referred to Medscape’s Novel Coronavirus Resource Center for the latest news, perspective, and resources.

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Background

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was first reported in December 2019 from Wuhan, Hubei province, China and has since spread throughout the world. The World Health Organization declared a global pandemic on March 11, 2020.

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Pathophysiology

Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection is characterized by an initial cytokine storm that can result in acute respiratory distress syndrome and macrophage activation syndrome. This initial phase is then followed by a period of immune dysregulation, which is the major cause of sepsis-related fatalities. [9]

While we are learning more about SARS-CoV-2 infection almost daily, differences between adult and pediatric disease are likely the result of changes within both immune function and the angiotensin-converting enzyme (ACE) 2 receptor, used by the virus to enter type II pneumocytes in the lung. Decreases in ACE-2 seen in animal models of aging result in changes in neutrophil influx and resultant lung injury. Thus, immunosenescence and changes in inflammatory responses with age likely account for the different spectrum and severity of disease in children versus adults and, furthermore, in neonates versus older children.

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Etiology

Transmission

Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is a highly infectious virus, [10]  and the main routes of transmission are respiratory droplets and contact with respiratory secretions and saliva. Aerosol particles may be another possible mode of transmission. SARS CoV-2 can remain viable on various surfaces for hours to days, although transmission is much more common through respiratory droplets than through fomites. [11]  Fecal shedding has been detected for several weeks after diagnosis, which has led to concerns about fecal-oral transmission of the virus. [12]

Based on limited data, no confirmed cases of vertical mother-to-fetus intrauterine transmission of the virus have been reported thus far. [13, 14]  To date, SARS CoV-19 has not been detected in breast milk.

Family clustering appears to play a major role in disease transmission. In one study, just over half of children with coronavirus disease 2019 (COVID-19) in China had evidence of transmission through family clustering. [15]  Most of the children in the US data also had exposure to a patient with COVID-19 in the household or community. [2]

Cruz and Zeichner suggested that children may play a major role in community-based viral transmission. [16]  They noted that children are more likely than adults to have upper respiratory tract involvement, including nasopharyngeal carriage. They may also have prolonged respiratory and fecal shedding. [17]  We continue to learn more as data emerge and more cases in children are described.

Additional data are emerging on the role of children in the spread of the disease. Simulation results from mathematical models of the effect of delayed school opening in South Korea showed that the number of cases could be reduced by at least 200 over a 3-week period. The models were based on different school opening dates and assumed a 10-fold increase in the transmission rate after schools opened. [18]

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Epidemiology

Relatively few cases of coronavirus disease 2019 (COVID-19) have been diagnosed in children, and the majority of those cases have been mild. In a report of 55,924 laboratory-confirmed cases of COVID-19 in China, only about 2.4% were in children and adolescents aged 19 years or younger. [1]  In a Morbidity and Mortality Weekly Report released by the US Centers for Disease Control and Prevention (CDC), of the 149,760 laboratory-confirmed US COVID-19 cases, 2572 (1.7%) occurred in children and adolescents younger than 18 years of age. [2]

Race-, sex-, and age-related demographics

No racial predilection has been observed in children, although emerging US data in adults suggest that minority communities may be affected disproportionately. [19]  In a retrospective Chinese study of 2143 children younger than 18 years with confirmed or suspected COVID-19, slightly more of the cases occurred in boys (56.6%) than in girls (43.4%), but the difference was not statistically significant. The ages of the children in the study ranged from 1 day to 18 years; the median age was 7 years. [20]  Slight male predominance was also seen in the US data, similar to what was observed in China. [2]

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Prognosis

Morbidity/mortality

Although most children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have either asymptomatic infection or mild illness, severe illness has been reported in 2.5% of pediatric cases in China, according to the World Health Organization (WHO). [1]  In a study of more than 2000 children in China, Dong et al found that approximately 4% of children with coronavirus disease 2019 (COVID-19) were asymptomatic, 51% had mild illness, and 39% had moderate illness. About 6% of pediatric patients had severe or critical illness, and one patient (a 14-year-old boy) died. [20]

The Chinese investigators also found that severe or critical illness was more common in infants and toddlers than in older children. More than 10% of infants had severe or critical illness compared with 7% of children aged 1-5 years, 4% of those aged 6-10 years, 4% of those aged 11-15 years, and 3% of those aged 16 years or older. [20]

The data from China showed that most children with COVID-19 recovered within 1-2 weeks after the onset of symptoms. [1]

Data on hospitalizations in the United States (US) are available for 749 cases in children (29% of COVID-19 cases in patients < 18 years of age). Of these cases, 147 (estimated range, 5.7-20%) were reported to be hospitalized, with 15 (0.58-2%) admitted to the intensive care unit. Children younger than 1 year of age accounted for the highest percentage of hospitalizations (15-62%). [2]

Two US case reports describe young infants who were hospitalized with COVID-19. In the first case, late-onset sepsis developed in a 3-week-old boy with confirmed SARS-CoV-2 infection. He was successfully treated with mechanical ventilation in a pediatric intensive care unit and was discharged. [21]  In the second case, a 5-week-old girl who had been admitted for fever without a source later tested positive for SARS-CoV-2. She had no respiratory distress, and her fever resolved within 30 hours. [22]

Complications

Recent media reports and a health alert from the New York State Department of Health have drawn attention to a newly recognized pediatric multi-system inflammatory syndrome that may be related to COVID-19. To date, more than 70 cases in children of a wide range of ages have been reported, with 3 deaths. [23, 24]

Symptoms are reminiscent of Kawasaki disease, atypical Kawasaki disease, or toxic shock syndrome. All patients had persistent fevers, and more than half had rashes and abdominal complaints. Interestingly, respiratory symptoms were rarely described. Many patients did not have polymerase chain reaction (PCR) results that were positive for COVID-19, but many had strong epidemiologic links with close contacts who tested positive. Furthermore, many had antibody testing that was positive for SARS-CoV-2. These findings suggest recent past infection, and this syndrome may be a post-infectious inflammatory syndrome.

Riphagen et al wrote in The Lancet to describe 8 children (aged 4-14 years) in the United Kingdom who had severe inflammation and shock. The authors noted significant cardiac involvement. The patients also developed effusions that were consistent with an inflammatory process. [25]

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Presentation

History

The typical incubation period of coronavirus disease 2019 (COVID-19) ranges from 1 to 14 days, with an average of 3-7 days [26, 27]  (mean, 6.4 days [28] ). However, longer incubation periods (up to 24 days) have been reported. [29]  In most of the early pediatric cases reported from China, the patient had a close contact with COVID-19 or was part of a family cluster of cases. [30]

Physical examination

Lu et al evaluated 171 children with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who were treated at the Wuhan Children’s Hospital in China. [6]  They reported that the most common signs and symptoms were cough (48.5% of patients), pharyngeal erythema (46.2%), and fever (41.5%). Other signs and symptoms included the following:

  • Diarrhea (8.8% of patients)
  • Fatigue (7.6%)
  • Rhinorrhea (7.6%)
  • Vomiting (6.4%)
  • Nasal congestion (5.3%)

About 29% of patients had tachypnea on admission, and about 42% had tachycardia. Slightly more than 2% of children had an oxygen saturation of < 92% during their hospitalization. [6]

Wu et al reported on the clinical characteristics of 68 pediatric patients with COVID-19 in China. [31] They found that the most common initial symptoms among the 44 symptomatic patients were cough (32.43%) and fever (27.03%). This finding also highlights the significant number of children with SARS-CoV-2 infection who are asymptomatic.

Rash has been reported in patients with COVID-19. [32]  An 8-year-old Italian girl with confirmed SARS-CoV-2 infection presented with an asymptomatic papulovesicular exanthem and mild cough. Her symptoms resolved without therapy within a week. [33]

According to Shen et al, children with SARS-CoV-2 infection who are at risk for severe disease include those with underlying conditions (eg, congenital heart disease, bronchial pulmonary hypoplasia, respiratory tract anomaly, abnormal hemoglobin level, or severe malnutrition) and those with immune deficiency or immunocompromised status (eg, as a result of long-term immunosuppressant use). [27]  The following conditions indicate a greater likelihood of severe disease:

  • Dyspnea: Respiration rate of >50 breaths/min in children aged 2-12 months; >40 breaths/min in children aged 1-5 years; >30 breaths/min in patients older than 5 years old (after excluding the effects of fever and crying).
  • Persistent high fever for 3-5 days.
  • Poor mental response, lethargy, disturbance of consciousness, and other changes of consciousness.
  • Abnormally increased levels of enzymes, such as myocardial and liver enzymes and lactate dehydrogenase.
  • Unexplained metabolic acidosis.
  • Chest imaging findings indicating bilateral or multi-lobe infiltration, pleural effusion, or rapid progression of conditions during a very brief period.
  • Age younger than 3 months.
  • Extrapulmonary complications.
  • Coinfection with other viruses or bacteria.

Xia et al found that 8 of 20 pediatric inpatients with COVID‐19 infection were co-infected with other pathogens, including influenza viruses A and B, mycoplasma, respiratory syncytial virus, and cytomegalovirus. [34]

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Differential Diagnoses

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Workup

Laboratory studies

A consistent pattern of laboratory abnormalities has not yet been identified in children with confirmed coronavirus disease 2019 (COVID-19). Early in the course of the disease, the white blood cell count is normal or decreased, and the lymphocyte count is decreased. The majority of patients have normal neutrophil counts.

In a study by Wu et al of 68 pediatric patients with COVID-19 in China, 23 children (31.08%) had abnormal white blood cell counts, and 10 (13.51%) had an abnormal lymphocyte count. [31] Slightly more than half of the children who underwent nucleic acid testing for common respiratory pathogens showed co-infection with pathogens other than SARS-CoV-2. This finding illustrates the need to test for COVID-19 even in the setting of other confirmed viral infections. Finally, 10 (13.51%) children in the study had reverse transcription–polymerase chain reaction (RT-PCR) analysis of fecal specimens, and 8 demonstrated the prolonged existence of SARS-CoV-2 RNA. This finding may suggest the risk of further transmission.

Levels of liver and muscle enzymes and myoglobin are increased in some children. Many patients have elevated C-reactive protein (CRP) levels and erythrocyte sedimentation rates. In severe cases, patients have high D-dimer levels and progressively decreasing lymphocyte counts. [27]

In a literature review of case reports involving 66 children and adolescents with confirmed COVID-19, Henry et al found that CRP and procalcitonin (PCT) levels were elevated in 13.6% and 10.6% of cases, respectively. [35]  In a study that included 20 pediatric inpatients in Wuhan, China, 80% of the children had elevated PCT levels. [6]  Because PCT values can increase significantly in systemic bacterial infections and sepsis, higher levels are strongly suggestive of bacterial co-infection in patients with COVID-19. [36]

Imaging studies

Common chest radiograph findings in children with COVID-19 pneumonia include bilaterally distributed peripheral and subpleural ground-glass opacities and consolidation. Nonspecific findings include the following [8] :

  • Unilateral ground-glass opacities and consolidation
  • Bilateral peribronchial thickening and peribronchial opacities
  • Multifocal or diffuse ground-glass opacities and consolidation without specific distribution

A common abnormality seen on computed tomography (CT) of the chest in children with COVID-19 is ground-glass opacity and nodules, which are usually bilateral. [6]  Other CT findings include the following:

  • Local patchy shadowing
  • Bilateral patchy shadowing
  • Interstitial abnormalities

Chest CT findings in children with COVID-19 are similar to those seen in adults. Xia et al reported that consolidation with a surrounding halo sign was observed in up to 50% of cases, and they suggested that this finding could be considered a typical sign in pediatric patients. [34]  Pleural effusion is rare. Radiographic changes may be seen in children without severe disease.

Imaging recommendations

Chest imaging is not generally recommended for initial screening of mildly symptomatic or asymptomatic children with suspected COVID-19 unless they are at risk for disease progression or have worsening symptoms, according to an international expert consensus statement. [8]

An initial chest radiograph may be appropriate for children with moderate to severe symptoms, and a chest CT scan may be warranted if the results could affect clinical management. A series of chest radiographs may be useful to assess therapeutic response, evaluate clinical worsening, or determine positioning of life support devices.

Post-recovery imaging may be appropriate for asymptomatic children who initially had moderate to severe illness and who may be at risk for long-term lung injury. In addition, follow-up imaging may be warranted for children with persistent or worsening symptoms regardless of the severity of the initial illness.

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Treatment

Supportive care

Recommendations for supportive care for children with coronavirus disease 2019 (COVID-19) are similar to those for adults. Among the recommendations are bed rest and ensuring sufficient calorie and water intake. Oxygen therapy is recommended for patients with hypoxia. Antibiotics should generally be reserved for children with bacterial co-infection. [27]

Investigational drugs and biologics

With the exception of remdesivir, no drugs or biologics have been demonstrated to be effective for the prevention or treatment of COVID-19 in children. Numerous antiviral agents and immunotherapies are being investigated as potential therapies. [37, 38, 39]

Remdesivir gained emergency use authorization (EUA) from the US Food and Drug Administration (FDA) on May 1, 2020, based on preliminary data showing a faster time to recovery of hospitalized patients with severe disease. [3, 4, 5]  Safety and effectiveness have not been assessed in children. Pediatric dosing within the EUA was derived based on pharmacokinetic data from adult healthy volunteers.

For more information on investigational drugs and biologics being evaluated for COVID-19, see Treatment of Coronavirus Disease 2019 (COVID-19): Investigational Drugs and Other Therapies.

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Guidelines

The American Academy of Pediatrics (AAP) has created a website for Critical Updates on COVID-19 to provide clinicians with resources.

American Academy of Pediatrics guidance on management of infants born to mothers with COVID-19

The American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases has issued guidance on the management of infants born to mothers with coronavirus disease 2019 (COVID-19). [14]   

Early evidence has shown low rates of peripartum severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and uncertainty concerning in utero viral transmission.

Neonates can be infected by SARS-CoV-2 after birth. Because of their immature immune systems, they are vulnerable to serious respiratory viral infections. SARS-CoV-2 may be able to cause severe disease in neonates.

Infection-control measures for birth attendants 

Staff attending deliveries involving women with COVID-19 should observe airborne, droplet, and contact precautions owing to the increased risk of aerosolized virus and the potential requirement for administering resuscitation to newborns with SARS-CoV-2 infection.

Separation of mother and newborn

If possible, mothers with COVID-19 should be separated from their newborns upon birth. These newborns should be kept in an area that is separate from other infants. Families who opt to keep the newborn near the mother should be educated concerning the potential risks of SARS-CoV-2 transmission.

Breastfeeding

As of April 2, 2020, SARS-CoV-2 has not been detected in breast milk. Mothers with COVID-19 may express breast milk after appropriate hand and breast hygiene to be fed to the newborn by caregivers without COVID-19.

Breastfeeding guidelines from AAP are available for post hospital discharge for mothers or infants with suspected or confirmed SARS-CoV-2 infection. [40]  

Neonatal testing for COVID-19

Following birth, newborns born to mothers with COVID-19 should be bathed to remove virus from the skin. Newborns should undergo testing for SARS-CoV-2 at 24 hours and 48 hours (if still at the birth facility) after birth. Centers with limited testing resources can make testing decisions on a case-by-case basis.

Follow-up

Newborns who have documented SARS-CoV-2 infection or who are at risk for postnatal transmission because of testing inability require frequent outpatient follow-up (via telephone or telemedicine) or in-person assessments for 14 days after discharge.

Precautions following discharge

After discharge from the hospital, mothers with COVID-19 should stay at least 6 feet away from their newborns. If a closer proximity is required, the mother should wear a mask and observe hand hygiene for newborn care until (1) her temperature has normalized for 72 hours without antipyretic therapy and (2) at least 1 week (7 days) has passed since the onset of symptoms.

Ongoing in-hospital neonatal care

Mothers with COVID-19 whose newborns require ongoing hospital care should maintain separation until (1) her temperature has normalized for 72 hours without antipyretic therapy, (2) her respiratory symptoms have improved, and (3) a minimum of 2 consecutive nasopharyngeal swab tests collected at least 24 hours apart are negative for SARS-CoV-2.

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Questions & Answers

Overview

How is coronavirus disease 2019 (COVID-19) characterized in children?

What are common symptoms of pediatric coronavirus disease 2019 (COVID-19)?

What are lab findings of pediatric coronavirus disease 2019 (COVID-19)?

What are the CT findings of pediatric coronavirus disease 2019 (COVID-19)?

How is pediatric coronavirus disease 2019 (COVID-19) treated?

What is the pathophysiology of pediatric coronavirus disease 2019 (COVID-19)?

How does pediatric coronavirus disease 2019 (COVID-19) spread?

Can coronavirus disease 2019 (COVID-19) be passed from mother to fetus or through breast milk?

What is the role of family clustering in the spread of pediatric coronavirus disease 2019 (COVID-19)?

What role do children play in the spread of coronavirus disease 2019 (COVID-19)?

Are school closings effective in preventing spread of coronavirus disease 2019 (COVID-19)?

How common is coronavirus disease 2019 (COVID-19) in children?

What are the age- and sex-based differences in the epidemiology of pediatric coronavirus disease 2019 (COVID-19)?

How common is severe or critical pediatric coronavirus disease 2019 (COVID-19) in China?

How common is hospitalization for pediatric coronavirus disease 2019 (COVID-19) in the United States?

What is the typical incubation period of coronavirus disease 2019 (COVID-19) in children?

What are common signs and symptoms of coronavirus disease 2019 (COVID-19) among hospitalized children?

What are the risk factors for severe coronavirus disease 2019 (COVID-19) in children?

How common are coinfections in children with coronavirus disease 2019 (COVID-19)?

Which lab findings are commonly found in pediatric coronavirus disease 2019 (COVID-19)?

What is the role of CT scanning in the workup of pediatric coronavirus disease 2019 (COVID-19)?

What are the components of supportive care in children with coronavirus disease 2019 (COVID-19)?

Which drugs are effective for pediatric coronavirus disease 2019 (COVID-19)?

What are the AAP guidelines for the management of infants born to mothers with coronavirus disease 2019 (COVID-19)?

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