Coronavirus Overview- August 2020

Coronavirus (COVID-19) Infection Among Children

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 US population,3 recent data show that 7.3% of all cases of COVID-19 in the United States reported to CDC were among children (as of August 3rd, 2020).4  The number and rate of cases in children in the United States have been steadily increasing from March to July 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 Cases, Data, and Surveillance page for current CDC data.

Infections and Transmission Among Children

It is unclear whether children are as susceptible to infection by SARS-CoV-2 compared with adults and whether they can transmit the virus as effectively as adults. Recent evidence suggests that children likely have the same or higher viral loads in their nasopharynx compared with adults7 and that children can spread the virus effectively in households and camp settings.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 in-person school and other activities may provide additional understanding about infections in children.

Symptoms and Severity of COVID-19 in Children

Clinical Presentation

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:

  • Fever
  • Cough
  • Headache
  • Muscle aches
  • Fatigue
  • Nasal congestion
  • New loss of taste or smell
  • Sore throat
  • Shortness of breath or difficulty breathing
  • Abdominal pain
  • Diarrhea
  • Nausea or vomiting
  • Poor appetite or poor feeding

Children infected with SARS-CoV-2 may have many of these non-specific symptoms, may 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 45% of pediatric infections are asymptomatic.17 The signs and symptoms of COVID-19 in children are similar to 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. Recent COVID-19 hospitalization surveillance data shows that the rate of hospitalization among children is low (8.0 per 100,000 population) compared with that in adults (164.5 per 100,000 population), but hospitalization rates in children are increasing. 5  While children have lower rates of mechanical ventilation and death than adults, 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit, which is the same in adults.5   

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.10,11,14 Of the children who have developed severe illness from COVID-19, most have had underlying medical conditions. 5

Testing and Recommendations for Isolation

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 home isolation for people not in healthcare settings.

Testing, Isolation, and Quarantine for School-Aged Children

As children return to school and other in-person activities, pediatric healthcare providers should be prepared to answer questions from families about testing and when it is safe 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 illnesses. Examples of non-COVID return to school policies include resolution of fever without antipyretics (Tylenol) for 24 hours for non-COVID 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 but must remain in quarantine for the 14-day incubation period even if results are negative, in accordance with CDC’s Quarantine If You Might Be Sick.

Source: CDC website- https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html