Coronavirus Disease 2019 (COVID-19) in Children 

Updated: Oct 10, 2021
  • Author: Ayesha Mirza, MD; Chief Editor: David J Cennimo, MD, FAAP, FACP, FIDSA, 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). In the United States and throughout the world, fewer cases of COVID-19 have been reported in children than in adults. Whereas children comprise about 22% of the US population, more than 14% of all cases of COVID-19 reported to the Centers for Disease Control and Prevention (CDC) were among children (as of October 9, 2021). [1]  Most cases in children are mild, and treatment consists of supportive care. 

The American Academy of Pediatrics (AAP) reports children represent 16.2% of all cases in the 49 states reporting by age; nearly 6 million children have tested positive in the United States since the onset of the pandemic as of October 6, 2021. This represents an overall rate of 7838 cases per 100,000 children. During the 2-week period of September 16 to September 30, 2021, there was an 7% increase in the cumulated number of children who tested positive, representing 380,333 new cases. In the week from September 23 to September 30, 2021, cases in children numbered 173,469 and represented 26.7% of the new weekly cases. Children were 1.6-4.2% of total reported hospitalizations, and between 0.1-1.9% of all child COVID-19 cases resulted in hospitalization. [2]

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. [3, 4, 5]  Other symptoms include the following:

  • Shortness of breath
  • Pharyngeal erythema/sore throat
  • Diarrhea
  • Myalgia
  • Fatigue
  • Rhinorrhea
  • Vomiting
  • Nasal congestion
  • Abdominal pain
  • Conjunctivitis
  • Rash
  • Loss of sense of taste (ageusia) and/or smell (anosmia)


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
  • Elevated D-dimer

Imaging studies

Common chest radiograph findings in children with COVID-19 pneumonia include bilaterally distributed peripheral and subpleural ground-glass opacities and consolidation. [6]

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


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

Remdesivir, an antiviral agent, is the only drug that has received full approval from the FDA for treatment of COVID-19. It is indicated for treatment of COVID-19 disease in hospitalized adults and children aged 12 years and older who weigh at least 40 kg. [7, 8]  An emergency use authorization (EUA) remains in place to treat pediatric patients weighing 3.5 kg to less than 40 kg or children younger than 12 years who weigh at least 3.5 kg. [7, 9]  The FDA expanded the EUA to include use in all hospitalized patients with confirmed or suspected COVID-19 disease, regardless of oxygen status. [10]  

The FDA has granted emergency use approvals (EUAs) for 3 SARS-CoV-2 vaccines since December 2020. Two are mRNA vaccines – BNT-162b2 (Pfizer) and mRNA-1273 (Moderna), whereas the third is a viral vector vaccine – Ad26.COV2.S (Johnson & Johnson). On May 10, 2021, the FDA extended the EUA for the BNT-162b2 vaccine to include younger adolescents aged 12-15 years. 

Convalescent plasma was granted EUA on August 23; however, safety and effectiveness in patients aged 18 years or younger have not been evaluated. The decision to treat patients < 18 years of age with COVID-19 convalescent plasma should be based on an individualized assessment of risk and benefit. For further information regarding administration, see the EUA COVID-19 Convalescent Fact Sheet for Health Care Providers. Numerous other antiviral agents, immunotherapies, and vaccines continue to be investigated and developed as potential therapies. 

EUAs have also been granted for outpatient monoclonal directed therapies (ie, casirivimab plus imdevimab, bamlanivimab plus etesevimab) for individuals aged 12 years and older who test positive and are at high risk of severe COVID-19 or hospitalization.

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



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. As of October 28, 2020 there were over 44 million confirmed cases of COVID-19 and over 1.1 million deaths reported globally. In the United States, confirmed cases as of October 28, 2020 is nearly 9 million with over 227,000 deaths. [10] As these numbers are constantly changing, the readers are referred to the Johns Hopkins Coronavirus Resource Center, CDC, and WHO websites for the most recent official numbers.



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. [11]

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 ACE2 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. The profound lymphopenia seen in patients with COVID-19 is likely the result of T lymphocyte infection and death that occurs as SARS CoV-2 infects these cells. [12]  

As the infection progresses, with acceleration in viral replication and epithelial-endothelial injury, the inflammatory response is accentuated. Interstitial mononuclear inflammatory infiltrates and edema followed by hyaline membrane formation occurs leading to acute respiratory distress syndrome (ARDS). These changes may be visible as ground glass opacities on a CT scan. Further injury to the endothelial tissues results in microthrombi formation and can lead to thrombotic complications such as pulmonary embolism, venous thrombosis, and thrombotic arterial complications as seen in severely ill patients. These complications have been seen more in adult than in pediatric patients, although they have been reported in the latter as well. Secondary sepsis in these individuals further contributes to the severity of the illness. [13, 14, 15]




Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is a highly infectious virus, [16]  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. [17] 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. [18]  Fecal shedding has been detected for several weeks after diagnosis, which has led to concerns about fecal-oral transmission of the virus. [19]

Mother-to-child transmission

Based on limited data, no confirmed cases of vertical mother-to-fetus intrauterine transmission of the virus have been reported thus far. [20, 21]  A multicenter study involving 16 Spanish hospitals reported outcomes of 242 pregnant women diagnosed with COVID-19 during their third trimester from March 13 to May 31, 2020. The women and their 248 newborns were monitored until the infant was 1 month old. COVID-19–positive mothers who were hospitalized had a higher risk of ending their pregnancy via cesarean section (P = .027). Newborns whose mothers had been admitted owing to their COVID-19 infection had a higher risk of premature delivery (P = .006). No infants died, and no vertical or horizontal transmission was detected. The percentage of infants exclusively breastfed at discharge was 41.7% and was 40.4% at 1 month. [22]

To date, SARS CoV-2 has not been detected in breast milk. A study by Chambers et al found human milk is unlikely to transmit SARS CoV-2 from infected mothers to infants. [23] The study included 64 milk samples provided by 18 mothers infected with COVID-19. Samples were collected before and after COVID-19 diagnosis. No replication-competent virus was detectable in any of their milk samples compared with samples of human milk that were experimentally infected with SARS CoV-2.

Family clustering

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. [24]  Most of the children in the US data also had exposure to a patient with COVID-19 in the household or community. [3]

Conversely, transmission of SARS-CoV-2 from 12 young children who acquired COVID-19 at childcare facilities to family members has been reported. Findings showed 25% of their close contacts became infected — most often mothers or siblings. Three of the children were asymptomatic, 2 of whom likely infected their contacts, including a mother who required hospitalization. One mildly symptomatic child too young for face masks (age 8 months) likely infected both parents. [25]

Posfay-Barbe et al reported on the transmission of SARS-CoV-2 within the families of 39 children (aged < 16 years) with confirmed infection in Geneva, Switzerland. [26]  In 31 of 39 households (79%), at least one adult family member had a suspected or confirmed SARS-CoV-2 infection before symptoms occurred in the child. In only 3 of 39 households (8%), the child was the first family member to develop symptoms. These findings suggest that children most often acquire COVID-19 from adult family members rather than transmitting the virus to them.

A study from South Korea found that older children and adolescents are more likely to transmit SARS-CoV-2 to family members than are younger children. The researchers reported that the highest infection rate (18.6%) was in household contacts of patients with COVID-19 aged 10-19 years and the lowest rate (5.3%) was in household contacts of those aged 0-9 years. [27]

In contrast, Canadian researchers found that infants and toddlers (up to age 3) were about 43% more likely than adolescents (aged 14-17 years) to transmit SARS-CoV-2 to household contacts. Data were analyzed from 6280 households with a pediatric COVID-19 case and a subset of 1717 households in which a household member younger than age 17 was the source of transmission. [28, 29]

Community transmission

Cruz and Zeichner suggested that children have a role in community-based viral transmission. [30]  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. [31]  We continue to learn more as data emerge and more cases in children are described.

More 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. [32]

In addition to schools, child care facilities can play a role in the transmission of SARS CoV-19. A CDC study found that 12 children who acquired COVID-19 at facilities in Utah spread the virus to at least 12 (26%) of 46 household contacts (confirmed or probable cases). [25]

The results of a South Korean study lend more data to unapparent infections in children that may be associated with silent COVID-19 community transmission. A case series of 91 children who tested positive for COVID-19 in South Korea showed 22% were asymptomatic during the entire observation period. Among 71 symptomatic cases, 47 children (66%) had unrecognized symptoms before diagnosis, 18 (25%) developed symptoms after diagnosis, and 6 (9%) were diagnosed at the time of symptom onset. Twenty-two children (24%) had lower respiratory tract infections. The mean (SD) duration of the presence of SARS-CoV-2 RNA in upper respiratory samples was 17.6 (6.7) days. [33]

However, researchers in Milan, Italy, suggest that the role of asymptomatic children in the transmission of SARS-CoV-2 infection may need to be reconsidered, based on the results of their case-control study. Among patients hospitalized for noninfectious conditions, who had no signs or symptoms of COVID-19, only 1 in 83 children (1.2%) tested positive for SARS-CoV-2, compared with 12 in 131 adults (9.2%). [34]

A US study failed to identify any instance of child to adult transmission, but less than half of participants had a household contact with COVID-19. This finding contrasts with data from other studies that implicated household sick contacts as the main driver of childhood infection. [35]  Teenagers have been shown to be the source of clusters of cases, which illustrates the role of older children. [36]



Fewer cases of coronavirus disease 2019 (COVID-19) have been diagnosed in children than in adults, and the majority of the pediatric cases have been mild. Whereas children comprise about 22% of the US population, more than 14% of all cases of COVID-19 reported to the Centers for Disease Control and Prevention (CDC) were among children (as of October 9, 2021). The number and rate of cases in children in the US have been steadily increasing. [1]

The true incidence of SARS-CoV-2 infection in children is not known, owing to the 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, which suggests that children may have less severe illness from COVID-19 compared with adults. [1]

The American Academy of Pediatrics (AAP) reports children represent 16.2% of all cases in the 49 states reporting by age; nearly 6 million children have tested positive in the United States since the onset of the pandemic as of October 6, 2021. This represents an overall rate of 7838 cases per 100,000 children. During the 2-week period of September 16 to September 30, 2021, there was an 7% increase in the cumulated number of children who tested positive, representing 380,333 new cases. In the week from September 23 to September 30, 2021, cases in children numbered 173,469 and represented 26.7% of the new weekly cases. Children were 1.6-4.2% of total reported hospitalizations, and between 0.1-1.9% of all child COVID-19 cases resulted in hospitalization. [2]

The loss of a parent or other caregiver is another toll that COVID-19 has taken on children. A CDC study found that more than 142,000 children in the United States have had a parent or grandparent caregiver die of the disease. Racial and ethnic minority groups have been disproportionately affected. For example, although Black children represent 14% of US children, about 26% of all those who lost a primary caregiver to COVID-19 were Black. [37, 38]

Race-, sex-, and age-related demographics

No racial predilection has been observed in children, although US data in adults suggest that minority communities are affected disproportionately. [39]  A CDC study found that a disproportionate percentage of the deaths related to COVID-19 among persons aged < 21 years occurred in Black and Hispanic youths. Of the 121 deaths reported to CDC by July 31, 2020, 94 (78%) were among Hispanic, non-Hispanic Black, and non-Hispanic American Indian/Alaskan Native persons. [40]  Emerging data suggest that children aged < 10 years may be less susceptible to SARS CoV-2 infection compared with adults. [41, 42]

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. [43]  Slight male predominance was also seen in the US data, similar to what was observed in China. [3]

While the numbers are much smaller than in adults, emerging data do suggest that children of color are disproportionately affected, similar to what has been reported in adults. [44]  





Overall, current data continue to support the fact that whereas children are infected with SARS-CoV-2 similar to adults, they are more likely to be asymptomatic or to have less severe disease. [45]

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). [46]  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. [43]

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. [43]

The data from China showed that most children with COVID-19 recovered within 1-2 weeks after the onset of symptoms. [46]

Data on hospitalizations from 25 states and New York City showed that children were 0.7-3.6% of total reported hospitalizations, and between 0.2-7.9% of all child COVID-19 cases resulted in hospitalization. [47]  

CDC researchers used data from the Premier Healthcare Database Special COVID-19 Release to identify patients aged 18 years or younger with an inpatient or emergency department encounter with a primary or secondary COVID-19 discharge diagnosis (March 1 to October 31, 2020). [48] Among 20,714 pediatric patients with COVID-19 (52.9% girls; 53.8% aged 12-18 years), nearly 1 in 3 patients had 1 or more chronic conditions (29.2%). Overall, 11.7% were hospitalized, and one-third of those hospitalized (31.1%) experienced severe COVID-19.

An association was observed between severe COVID-19 and having 1 or more chronic conditions versus having none (adjusted odds ratio, 3.27). Additionally, severe COVID-19 was more likely in hospitalized children aged 2-5 years or 6-11 years compared with those aged 12-18 years (adjusted odds ratios, 1.53 and 1.53, respectively); this finding was also true for male versus female patients (adjusted odds ratio, 1.52). [48]


The CDC reports that 121 deaths related to SARS-CoV-2 infection occurred among persons younger than 21 years of age in the United States from February to July 2020. Of the persons who died, 63% were male, 10% were aged < 1 year, 20% were aged 1-9 years, and 70% were aged 10-20 years. Ninety-one (75%) had an underlying medical condition. [40]




The typical incubation period of coronavirus disease 2019 (COVID-19) ranges from 1 to 14 days, with an average of 3-7 days [49, 50]  (mean, 6.4 days [51] ). However, longer incubation periods (up to 24 days) have been reported. [52]  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. [53]  

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. [4]  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. [4]

Wu et al reported on the clinical characteristics of 68 pediatric patients with COVID-19 in China. [54] 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.

We know now that gastrointestinal manifestations often accompany the initial presentation with fever. These commonly include abdominal pain, diarrhea, and/or vomiting. Neurologic manifestations have also been described. [55, 56, 57]

Rash has been reported in patients with COVID-19. [58]  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. [59]

Hoang et al published a systematic review of 7780 pediatric COVID-19 cases, comprising 131 studies spanning 26 countries. The mean age was 8.9 years (SD, 0.5), and 75% were exposed to family with COVID-19. The most common symptoms included fever in 59% and cough in 56%; 19% were asymptomatic. The overall mortality rate was 0.09%. [60]  In general, symptoms are less pronounced in children when compared with adults. [3]

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). [50]  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. [61]

Chao et al retrospectively reviewed medical charts for all children aged 1 month to 21 years between March 15 and April 13, 2020 who were seen at Children’s Hospital Emergency Department at Montefiore in New York City. Sixty-seven patients (34.5%) tested positive for SARS-CoV-2 infection. Of these, 46 patients were admitted to the hospital, with 13 requiring PICU care. The most common symptoms at admission were cough (63%) and fever (50.9%). The clinical symptom found to be significantly associated with PICU admission was shortness of breath (92.3% vs 30.3%; P< .001). [62]  


Differential Diagnoses



Laboratory studies

A consistent pattern of laboratory abnormalities has not yet been identified in children with confirmed coronavirus disease 2019 (COVID-19), although some patterns are emerging. [63]  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. [54] 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. [50]

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. [64]  In a study that included 20 pediatric inpatients in Wuhan, China, 80% of the children had elevated PCT levels. [4]  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. [65]

For more information on testing, please see Laboratory Studies in Coronavirus Disease 2019 (COVID-19).

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 [6] :

  • 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. [4]  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. [61]  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. [6]

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.



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. [50]



The American Academy of Pediatrics urges children and adolescents aged 12 years and older to receive the COVID-19 vaccine.

The FDA has granted emergency use approvals (EUAs) for 3 SARS-CoV-2 vaccines since December, 2020. Two are mRNA vaccines – BNT-162b2 (Pfizer) and mRNA-1273 (Moderna), whereas the third is a viral vector vaccine – Ad26.COV2.S (Johnson & Johnson).

As of May 2021, BNT-162b2 (Pfizer) is the only vaccine available for children aged 12-18 years to prevent COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The EUA in adolescents aged 16-17 years is based on extrapolation of safety and effectiveness from adults aged 18 years and older. On May 10, 2021, the FDA expanded the EUA to include adolescents aged 12-15 years. The phase 3 trial data that is included in the EUA lists the vaccine as 100% effective in preventing SARS-CoV-2 infection in this age group. There were no cases of COVID-19 disease in adolescents aged 12-15 years who received the vaccine (n = 1,119), compared with 18 cases in those who received placebo (n = 1,110).

The mRNA-1273 vaccine (Moderna) was reported to be 96% effective in an initial analysis of a phase 2/3 trial (n = 3,235) in adolescents aged 12-17 years. The EUA is for patients aged 18 years and older. Submission of data to support extending the EUA to adolescents is planned for mid-2021.

Clinical trials for other vaccines are ongoing in adolescents and children. As of September 2021, clinical trials in younger children aged 5 years and older have been completed for the mRNA vaccines.

Investigational drugs and biologics

Antiviral agents

Remdesivir, an antiviral agent, is the only drug fully approved for treatment of COVID-19. [8]  Numerous antiviral agents and immunotherapies are being investigated as potential therapies. [66, 67, 68]

Remdesivir is indicated for treatment of COVID-19 disease in hospitalized adults and children aged 12 years and older who weigh at least 40 kg. [8]  An emergency use authorization (EUA) remains in place to treat pediatric patients weighing 3.5 kg to less than 40 kg or children younger than 12 years who weigh at least 3.5 kg. [9]   

The initial EUA for remdesivir was based on preliminary data analysis of the Adaptive COVID-19 Treatment Trial (ACTT) and was announced on April 29, 2020. The final analysis included 1,062 hospitalized patients with advanced COVID-19 and lung involvement, showing that patients treated with 10 days of remdesivir recovered faster than similar patients who received placebo. Results showed that patients who received remdesivir had a 31% faster time to recovery than those who received placebo (P< 0.001). Specifically, the median time to recovery was 10 days in patients treated with remdesivir compared with 15 days in those who received placebo. Patients with severe disease (n = 957) had a median time to recovery of 11 days compared with 18 days for placebo. A statistically significant difference was not reached for mortality by day 15 (remdesivir 6.7% vs placebo 11.9%) or by day 29 (remdesivir 11.4% vs placebo 15.2%). [7]  

Remdesivir has been available through compassionate use to children with severe COVID-19 disease since February 2020. A phase 2/3 trial (CARAVAN) of remdesivir was initiated in June 2020 to assess safety, tolerability, pharmacokinetics, and efficacy in children with moderate-to-severe COVID-19. CARAVAN is an open-label, single-arm study of remdesivir in children from birth to age 18 years. [69]

Data were presented on compassionate use of remdesivir in children at the virtual COVID-19 Conference held July 10-11, 2020. Results showed most of the 77 children with severe COVID-19 improved with remdesivir. Clinical recovery was observed in 80% of children on ventilators or extracorporeal membrane oxygenation and in 87% of those not on invasive oxygen support. [70]

A study funded by the National Institutes of Health will assess the pharmacokinetics of drugs currently given to children and adolescents with COVID-19, including antiviral and anti-inflammatory agents. The goal of this study is to provide specific dosing recommendations and safety data for these drugs in pediatric patients. Data will be collected at more than 40 sites throughout the United States. [71]  

Antibody-directed therapy

Bamlanivimab plus etesevimab 

Bamlanivimab is no longer recommended as monotherapy owing to viral variants that are resistant to bamlanivimab. The manufacturer asked the FDA to rescind the original EUA for monotherapy on April 16, 2021 owing to decreased efficacy to circulating variants in the United States. Instead, use in combination with etesevimab is recommended. [72]  However, the proportion of SARS-CoV-2 variants of concern (VOCs) with reduced susceptibility to bamlanivimab plus etesevimab (P.1, B.1.351, and B.1.617) sequenced from US residents continues to grow. As of June 11, 2021, at least 10 states have ceased using this combination and recommend prescribing casirivimab plus imdevimab or sotrovimab. 

An interim analysis from the Blocking Viral Attachment and Cell Entry with SARS-CoV-2 Neutralizing Antibodies (BLAZE-1) study provided the basis of support for the EUA. In this ongoing phase 2 trial, bamlanivimab given to people recently diagnosed with COVID-19 in the ambulatory setting showed a reduced rate of hospitalization or emergency department visits compared with placebo. [73]

On February 25, 2021, the FDA issued an EUA for bamlanivimab and etesevimab, administered together, also for the treatment of mild to moderate COVID-19 in patients 12 years and older weighing at least 40 kg. According to the FDA, the data from Trial PYAB (NCT04427501) showed a significant clinical benefit of reduction in hospitalization and all-cause mortality by Day 29 for the combination therapy compared to placebo in outpatients at high risk of progression to severe COVID-19. 

Casirivimab plus imdevimab

On November 21, 2020, the FDA issued an EUA for casirivimab and imdevimab, administered together, for the treatment of mild to moderate COVID-19 in patients 12 years and older weighing at least 40 kg. In June 2021, the EUA was updated with a lower IV dose of casirivimab 600 mg and imdevimab 600 mg. The update also allows administration as a SC injection for when an IV infusion is not feasible. 

Efficacy and safety for use of monoclonal antibodies in pediatric patients is currently lacking. In an initial guidance statement dated January 2021, the Pediatric Infectious Diseases Society suggests against the routine administration of monoclonal antibody therapy for children and adolescents with COVID-19, including those designated by the FDA as at high risk of progression to hospitalization or severe disease. [74]  Clinicians and health systems choosing to use these agents on an individualized basis should determine the precise populations that would benefit. An example of such criteria was developed by clinicians at Children’s Minnesota, Mayo Clinic, and the University of Minnesota. 


Sotrovimab (VIR-7831; VIR Biotechnology; GlaxoSmithKline) is a monoclonal antibody that binds to conserved epitope of the spiked protein of SARS-CoV-1 and SARS-CoV-2, thereby indicating unlikelihood of mutational escape. This is supported by a preclinical trial showing it retained ability to neutralize SARS-CoV-2 variants (ie, B.1.1.7, B.1.351, P.1). [75]  The FDA granted emergency use authorization on May 26, 2021. 

The EUA submission was based on an interim analysis of the COMET-ICE phase 3 trial. The trial evaluated VIR-7831 as monotherapy for early treatment of COVID-19 in adults at high risk of hospitalization or death. The interim analysis demonstrated an 85% reduction in hospitalization or death in those who received a single IV dose of VIR-7831 (n = 291) compared with placebo (n = 292) (P = 0.002). [76]  

Additional trials for VIR-7831 include comparison of IM and IV administration in low-risk adults (COMET-PEAK), IM use in high-risk adults (COMET-TAIL), and IM administration in uninfected adults to prevent symptomatic infection (COMET-STAR).  

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.


Follow-up Care

The American Academy of Pediatrics (AAP) issued interim guidance on follow-up care for infants, children, and adolescents who have had COVID-19. [77] All patients who test positive for SARS-CoV-2 should have at least one follow-up visit with their primary care provider. Follow-up visits should occur after the recommended quarantine period and before the patient returns to physical activity.

In general, during the first 4-12 weeks after the illness, the AAP recommends a conservative approach that involves minimal diagnostic assessment. If concerns persist beyond 12 weeks, the AAP advises further testing or referral to a multidisciplinary post-COVID-19 clinic. According to the AAP, the following are some of the ongoing or residual symptoms that can occur after a SARS-CoV-2 infection in children and adolescents:

  • Respiratory symptoms, such as cough, chest pain, and exercise-induced dyspnea
  • Cardiac involvement, including myocarditis
  • Anosmia and/or ageusia, which typically resolve in several weeks in children
  • Neurodevelopmental impairment, such as delays or changes in cognitive, language, academic, motor, or mood/behavior domains
  • Cognitive “fogginess” or fatigue, which may manifest as inattentiveness or slower reading or processing
  • Physical fatigue and/or poor endurance
  • Headache, which is common both during and after SARS-CoV-2 infection
  • Mental and behavioral health problems

Multisystem Inflammatory Syndrome in Children

In mid-April 2020, over a period of 10 days, an unprecedented cluster of cases was reported from the South Thames Retrieval Service in London. They noted eight children who presented with signs of hyperinflammation and shock with features similar to Kawasaki disease (KD) or toxic shock syndrome. Four of these children had known family exposure to COVID-19. All tested negative for SARS-CoV-2 on bronchoalveolar lavage or nasopharyngeal aspirates. Seven of these children were noted to have abnormalities in cardiac function on echocardiograms, including coronary dilatations with giant coronary aneurysm noted in one child a week after discharge from the intensive care unit. [78]  This was the first case cluster highlighting what has since been termed multisystem inflammatory syndrome in children (MIS-C) by the CDC. Since the initial reporting, multiple case clusters have been reported from different countries and, as of October 1, 2020, there were 1,027 cases reported in the United States with a total of 20 deaths. [79]  The CDC case definition for MIS-C is as follows:

  • An individual aged < 21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
  • No alternative plausible diagnoses; AND
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or exposure to a suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms.

Since initial reporting, the American Academy of Pediatrics has also published interim guidelines on MIS-C. [80]   

Children reported seem to be predominantly Hispanic and Black (non-Hispanic). This is different from KD, which seems to affect children of Asian descent more often. Also unlike KD, affected children have been predominantly in the 5-9 and 9-14 age groups. The pathophysiology of MIS-C in children has been described in its initial stages, with COVID-19 infection triggering macrophage activation followed by helper T-cell activation. This in turn leads to massive cytokine release with B-cell and plasma cell activation and the production of antibodies, which leads to immune dysregulation and a hyperimmune response. [81]   

Children with severe MIS-C present with a cytokine storm believed to be related to delayed interferon gamma responses and slow viral clearance, further leading to more pronounced inflammation. [82]  They present with systemic signs of inflammation, often with significant cardiac, neurologic, and/or hematologic abnormalities. They require a multidisciplinary team of individuals who should be involved in their management, including intensivists and pediatric infectious disease, rheumatology, cardiology, and hematology specialists. Guidelines for management have been proposed by several of these specialty groups. [83, 84, 85, 86]  

Gaining evidence to support therapeutic decisions for pediatric patients is challenging. [87]  Studying MIS-C is challenging, as it is a rare syndrome and patients present at differing times from the time of diagnosis with COVID-19. Outcomes of patients with MIS-C may be difficult to interpret, owing to whether observations were early in the pandemic when little was known regarding treatment, changing therapeutic strategies over time, and geographical differences for available therapies. 

An international observational cohort study collected data regarding clinical outcomes. Data regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021 were analyzed, of which 490 cases met the World Health Organization criteria for MIS-C. Among 614 children with suspected MIS-C, 246 received primary treatment with intravenous immunoglobulin (IVIG) alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone. Twenty-two children received other treatment combinations, including biologic agents, while 39 received no immunomodulatory therapy. In this study, recovery from MIS-C did not differ between regimens of IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone. The observational study occurred during the first, second, and third waves, and SARS-CoV-2 variants had emerged. [87]   

In contrast, surveillance data on inpatients younger than 21 years (n = 518; median age, 8.7 years) with MIS-C admitted to 1 of 58 US hospitals showed a lower risk of new or persistent cardiovascular dysfunction when treated with IVIG plus glucocorticoids than IVIG alone. The timing of this study was earlier in the pandemic, during the first wave in the United States and before SARS-CoV-2 variants emerged. [88]   

A randomized controlled trial is recruiting patients presenting with MIS-C who have received IVIG but warrant further anti-inflammatory therapy to 1 of 3 treatment arms (ie, infliximab, steroids, or anakinra). However, recruitment will likely be slow for this rare condition, and results are not expected until the end of 2023. [89]   

Ahmed et al published a review of 39 MIS-C reports from 1/1/20-7/25/20 comprising 662 patients. The mean age was 9.3 years, and mortality was 1.7%. The most common symptoms were fever (100%), abdominal pain or diarrhea (74%), and vomiting (68%). Levels of inflammatory markers, troponin, and D-dimer were highly abnormal in most cases. In cases in which an echocardiogram was performed, over half were abnormal. [90]

A case series compared 539 patients who had MIS-C with 577 children and adolescents who had severe COVID-19. The patients with MIS-C were typically younger (predominantly aged 6-12 years) and more likely to be non-Hispanic Black. They were less likely to have an underlying chronic medical condition, such as obesity. Severe cardiovascular or mucocutaneous involvement was more common in those with MIS-C. Patients with MIS-C also had higher neutrophil to lymphocyte ratios, higher CRP levels, and lower platelet counts than those with severe COVID-19. [91]

In a cross-sectional study that included 1733 patients, CDC researchers identified two peaks in the incidence of MIS-C that each occurred about 2-5 weeks after peaks in COVID-19. This finding suggests that delayed immunologic responses to SARS-CoV-2 infection lead to the development of MIS-C. The researchers also found that young children (aged 0 to 4 years) had fewer cardiovascular complications than older children and adolescents. Patients with MIS-C who were aged 18-20 years were the most likely to have myocarditis, pneumonia, and acute respiratory distress syndrome. [92]

Farooqi et al reported on longitudinal outcomes in a cohort of 45 children who were hospitalized with MIS-C. Most of the children (84%) had no underlying medical conditions. All of the patients received steroids and immunoglobulins (2 g/kg), as well as enoxaparin prophylaxis or low-dose aspirin and GI prophylaxis. After a follow-up period of 9 months, only one child had persistent mild cardiac dysfunction. [93]

For more information on testing for patients with MIS-C, please see Laboratory Studies in Coronavirus Disease 2019 (COVID-19).


SARS CoV-2 Infection in Neonates

The American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases initially issued guidance on the management of infants born to mothers with coronavirus disease 2019 (COVID-19) on April 2, 2020. [21]  These guidelines have since been revised as more data have emerged. [94]  

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. To date there does not seem to be any conclusive evidence indicating vertical transmission of COVID-19 from infected pregnant mothers to their neonates, [20]  though some cases have been suspected.

A series of 66 British infants (aged < 28 days) with COVID-19 was described, and an incidence of 5.6 [95% CI, 4.3-7.1] per 10,000 live births was estimated. The most common symptoms were fever and poor feeding reported in approximately one-third of the patients. Forty-two percent had severe neonatal SARS-CoV-2 infection, 24% of those were born preterm. Only 5% required mechanical ventilation. Twenty-six percent of infants with confirmed infection were born to mothers with known perinatal SARS-CoV-2 infection; 3% were considered to have possible vertically acquired infection (SARS-CoV-2–positive sample within 12 hours of birth when the mother was also positive). Twelve percent of the infants had suspected nosocomially acquired infection. At the time of publication, 88% of the babies had been discharged home, 11% were still admitted, and 2% had died of a cause unrelated to SARS-CoV-2 infection. [95]

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. A recent review of neonates born to mothers with perinatal confirmed COVID-19 infection showed that severe maternal disease can lead to fetal distress, premature delivery, and other adverse outcomes. These small case series are predominantly out of China. [96]

Another case series of 33 infants born to mothers with COVID-19 from China also described a varying course of the disease with an overall favorable outcome, including a 31-weeks' gestation infant who developed Enterobacter sepsis; however, the baby recovered. [97]

In an international cohort study, Villar et al found that 12.1% of neonates who were born to SARS-CoV-2–positive mothers also tested positive. Neonatal test positivity was associated with cesarean delivery (relative risk [RR] 2.15; 95% CI, 1.18-3.91) but not with breastfeeding (RR, 1.10; 95% CI, 0.66-1.85). The infants who tested positive for SARS-CoV-2 were at substantially higher risk for requiring neonatal intensive care (RR, 6; 95% CI, 3.3-10.9). Overall, the risk of severe neonatal complications was significantly greater among infants born to mothers with COVID-19, compared with those born to women without COVID-19. [98, 99]

The results of a Swedish prospective cohort study, which included 88,159 infants, demonstrated that SARS-CoV-2 infection during pregnancy is associated with adverse outcomes in neonates. Norman et al found higher rates of respiratory disorders, hyperbilirubinemia, and admission for neonatal care in infants born to mothers who tested positive for SARS-CoV-2. [100, 101]

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

A pilot study suggests that rooming in for term or near term neonates may be considered for mothers with asymptomatic COVID-19 infection. Infection control measures still need to be followed strictly. [102]

A more recent study looking at 49 infants (36 weeks' gestational age) who were allowed to room in with their mothers with asymptomatic COVID-19 infection did not demonstrate any symptoms up to two weeks after discharge. One infant did have a positive reverse transcriptase polymerase chain reaction (RT_PCR), but repeat RT-PCR at 48 hours was negative. [103]  


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. [104]  

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. [94]


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 symptomatic 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.

COVID-19 vaccines in pregnant and lactating women

A cohort study (n = 131) by Gray et al found mRNA SARS-CoV-2 vaccines generated humoral immunity in pregnant and lactating women, similarly to that observed in nonpregnant women. All serum titers from vaccination were significantly higher compared with titers induced by SARS-CoV-2 infection during pregnancy (P< .0001). Importantly, vaccine-generated antibodies were present in all umbilical cord blood and breast milk samples, showing immune transfer to neonates via placenta and breast milk. [105]



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

In addition to guidance on the management of infants born to mothers with coronavirus disease 2019 (COVID-19), which is summarized below, the AAP has provided guidance on the following topics:


Questions & Answers


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

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