This post was originally published on April 27, 2020. For up to date information on Pediatric Multi-system Inflammatory Syndrome, see our latest article .
By now we know COVID-19 is particularly dangerous for the elderly and individuals with underlying medical conditions. However, the disease seems to greatly spare kids and teenagers—with most infected children presenting with only mild or moderate symptoms or commonly, no symptoms at all.
Still, as Parsley Health New York’s resident pediatrician and a parent myself, it’s important to understand how COVID-19 can affect children and what to do if you suspect your child may have the disease caused by the novel coronavirus. Below, I’ll guide you through what we currently know about the disease and its effects on kids.
Compared to adults, there is significant evidence that children are far less affected by COVID-19 than almost any other group. In fact, as of February 2020, only 2.4 percent of both the confirmed and suspected cases in China were reported in the pediatric population—data that mirrors the WHO report which found that individuals under 18 only made up 2.4 percent of all reported infections. A systematic literature review identified 45 papers and letters through mid-March showing that children accounted for a mere 1‐5 percent of diagnosed cases.
The specific trends in pediatric infections suggest that young men have a slightly higher chance of contracting the illness with the age range of patients varying widely. In their pre-publication release , Chinese researchers found that amongst the 2,143 pediatric cases reviewed, the median age was about seven years old with 56.6 percent of the cases being found in boys. Similarly, in a separate study , 65 percent of 20 affected pediatric patients under 14 years old with COVID-19 were male as well.
Findings in the United States indicate that among the 149,082 reported cases for which age was known, only 2,572—or 1.7 percent—of the cases were among children under 18 years old. The median age was 11 years of age with nearly one third of reported pediatric cases occurring in children aged 15-17 years, followed by children aged 10-14 years old.
One explanation is that children are not actually spared but rather do not show signs of illness even if infected. In other words, children and adolescents are serving as asymptomatic carriers and innocently playing a major role in ongoing community-based transmission—unwittingly passing on COVID-19 to those at higher risk. A study out of China that looked at 2,000 children found that 13 percent with suspected or confirmed COVID-19 cases were completely symptom-free. However, this percentage presumably understates the true rate of asymptomatic infection in children—since those that aren’t experiencing symptoms are unlikely to be tested.
Further complicating this is that studies show that the average incubation period in pediatric patients, the time between exposure to infection when individuals can begin to be contagious, is about six and a half days—a longer period than what is even being reported in adults .
Another explanation for this is that young children are often exposed to more coronaviruses in childhood which has given them partial immunity to this novel and more virulent strain. A systematic literature review on the current knowledge of COVID-19 and children, mentions that children tend to have many viral infections, and this repeated viral exposure supports the immune system when it responds to SARS‐CoV‐2—the virus that causes COVID-19.
Research also shows that children are having less immune dysfunction during and after the SARS-CoV-2 infection than adults. In other words, younger children do not mount the aggressive immune response (known as “cytokine storm”) in response to the virus that adults do. Surprisingly, most children had normal white blood cell counts following infection, suggesting less damage to their immune systems—data that contrasts findings in adults who seem to show an overall decrease in white blood cells, specifically lymphocytes, at the early stage of disease leading to an increased likelihood of severe illness and respiratory distress.
Symptoms of COVID-19 in adults aged 18-64 are most commonly fever, cough, and shortness of breath, with 93 percent reporting at least one of these. These signs were less frequently reported among pediatric patients (73 percent). Only around half of children present with fever or cough and less than 15 percent experience shortness of breath. In adults, symptoms can also include muscle aches and pains, sore throat, and headache, all of which are less commonly reported in pediatric patients. Compared to greater than 30 percent of adults reporting gastrointestinal symptoms, research shows that fewer than 10 percent of children with symptomatic infections develop diarrhea and vomiting from COVID-19.
Interestingly, many infectious diseases are known to affect children differently than adults such as Group A streptococcus (strep throat), Epstein-Barr virus, and Lyme disease. For COVID-19, research shows that severe infections in adults result in low blood oxygen levels known as hypoxemia, respiratory failure, or organ dysfunction. However, among symptomatic children with severe infections, only 5 percent had low blood oxygen levels and only 0.6 percent progressed to acute respiratory distress syndrome (ARDS) or multiorgan system dysfunction—rates significantly lower than those seen in adults.
Despite the low rate of severe infection, some children with severe illness do require hospitalization. A study from the US found that as of April 6, 2020 out of the estimated 176,190 children infected with SARS-CoV-2, 74 children nationwide had been admitted to pediatric intensive care units (PICU). Yet, experts project that if COVID-19 continues to spread over the coming months, up to 10,865 children could require PICU admission, 99,073 could require hospitalization for severe pneumonia, and 37.0 million could be infected with SARS-CoV-2. Thus, despite the current lower rates of PICU admissions of children, we could unfortunately face an increase if there continues to be accelerated spread of COVID-19.
There are specific groups of children with an increased risk for more severe infection. Interestingly, despite the median age for COVID-19 being 7-11 years old, preschool-aged children and infants were found to be more likely to have severe illness than older children.
Outside of age, underlying lung issues or those with immunocompromising conditions also were at higher risk of more severe infection—similar risk factors found in adults. The CDC reports that among 345 pediatric cases, 80 (23 percent) had at least one underlying condition. The most common underlying conditions were chronic lung disease (including asthma), cardiovascular disease, and immunosuppression.
A separate risk factor for COVID-19 in children is having another viral infection. Prior studies have shown that children from whom coronaviruses are detected in the respiratory tract can have viral co-infections in up to two-thirds of cases. This may be due to decreased immunity while concurrently fighting another viral infection.
At-home recovery including ample rest and fluids appears to be sufficient in the majority of pediatric cases. While there are currently no known supplements that directly treat COVID-19, specific vitamins and nutrients can be given to children to help support immune function and diminish the severity of symptoms.
Top recommendations include vitamin C, vitamin D3, broad-spectrum probiotics , omega-3 fatty acids, zinc, and elderberry extract. However, before adding anything new into your child’s regimen, it is important to work with their pediatrician to properly dose all supplements and medications for optimal immune support and treatment guidelines based on your child’s age, weight, medical history, and current symptoms. For more severe pediatric cases, pharmaceutical intervention may be necessary.
There are some other rare possible presentations of SARS-CoV-2 in children including ischemic stroke which is more common in adults, but have been reported in some cases in children. Skin lesions or “covid toes”—which look like red-purple nodules on the feet—have been seen in children and adults. In addition, there have been reports of encephalitis and sudden cardiac death and pulmonary embolism.
There’s also growing concern regarding a newly recognized inflammatory syndrome seen in children that appears potentially during active COVID-19 infection or more likely 4-6 weeks after exposure. You can learn more about Pediatric Multi-system Inflammatory Syndrome in another one of our articles here .
Overall, it is particularly important to be aware of the rising anxiety many children may be experiencing during this uncertain time. If you have children, make sure to provide and discuss age-appropriate COVID-19 information with them to help manage their fear and anxiety around the current climate. Speak with your provider about resources to help know what is appropriate to share with your children.
At Parsley Health, we are actively staying in touch with our members—both children and adults —while supporting them in navigating the onset of any symptoms. Our care team is here to support our members through messaging 7 days per week and online visits as needed. We encourage those that are not members to stay in close contact with their personal healthcare providers and their child’s pediatrician during this time and especially if symptoms arise.
Dr. Gabriella Safdieh is a certified Functional Medicine Physician who specializes in pediatrics and rheumatology. She trained at University of Pennsylvania School of Medicine, New York University School of Medicine, the Hospital for Special Surgery, and the Institute for Functional Medicine.