Information for Pediatric Healthcare Providers

More information

For evidence-based treatment recommendations for COVID-19, visit the Infectious Diseases Society of America (ISDA) Guidelines on the Treatment and Management of Patients with COVID-19 and the American College of Physicians Clinical Guidelines and Recommendations on COVID-19. Also see the American Academy of Pediatrics (AAP) Critical Updates on COVID-19 and the Centers for Disease Control and Prevention’s (CDC’s) Vaccines for COVID-19.

Incidence

Visit the Pediatric Data page of the COVID Data Tracker to view emergency department and hospitalization data for children.

Incubation period and clinical presentation

Studies performed during high levels of Omicron variant transmission reported a median incubation period of 3–4 days ^1,2

The most common symptoms of COVID-19 in children are fever and cough, but many children can experience sore throat, rhinorrhea, headache, fatigue, shortness of breath, or gastrointestinal symptoms, including nausea, vomiting, or diarrhea^3,4,5,6. Some case studies conducted during high levels of Omicron variant transmission have reported a substantial increase in croup during a decline in the prevalence of all other respiratory viral pathogens known to cause croup^7,8.

The signs and symptoms of COVID-19 in children can be similar to those of other infections and noninfectious processes, making symptom-based screening for identification of SARS-CoV-2 in children particularly challenging⁹.

Severity and underlying medical conditions

Most children with SARS-CoV-2 infection experience asymptomatic or mild illness, but some children are at risk of developing severe illness, including hospitalization, admission to an ICU, placement on invasive mechanical ventilation, and death¹⁰. Studies have found that some underlying medical conditions including obesity; diabetes; cardiac, lung, and neurologic disorders; and medical complexity increase the risk of severe outcomes from COVID-19^11,12,13,14, and having more than one pre-existing comorbidity is associated with an increased risk of severe illness^12,15.

Studies have found that age may also be associated with risk of severe illness, and an evaluation of surveillance data from children aged >7 days and <18 years reported that infants made up a disproportionate number of severe acute COVID-19 cases¹⁶. The rate of hospitalization among infants may be increased by the greater need for evaluation in young infants with fever, prematurity, the propensity for very young children to develop viral co-infection, and ineligibility for vaccination, among other factors^17,11,13.

Vaccination is effective at reducing risk of hospitalization¹⁸ in children and adolescents and critical illness in adolescents^18,19. Completion of a 2-dose mRNA COVID-19 vaccination series during pregnancy was associated with a reduced risk of hospitalization for COVID-19, including for critical illness, among infants younger than 6 months of age²⁰. Recommendations and clinical considerations for administration of COVID-19 vaccination can be found at CDC’s Interim Clinical Considerations for Use of COVID-19 Vaccines.

Pre-exposure prophylaxis

Pre-exposure prophylaxis (prevention) medication is available for some people who are moderately or severely immunocompromised for additional protection against COVID-19.

Pemivibart (Pemgarda™) is a monoclonal antibody for COVID-19 pre-exposure prophylaxis in adults and adolescents (12 years of age and older weighing at least 40 kg) who are moderately or severely immunocompromised and unlikely to mount an adequate immune response to COVID-19 vaccination and who meet the FDA-authorized conditions for use. Pemivibart may provide another layer of protection against COVID-19 in addition to the protection provided through vaccination and can be given at least 2 weeks after receiving a dose of COVID-19 vaccine.

Pemivibart is administered as a single intravenous infusion over 60 minutes at a healthcare facility. If continued protection is needed, additional doses should be administered every 3 months. Pemivibart is still being studied and there is limited information about the safety and effectiveness of Pemivibart in preventing COVID-19. Healthcare providers should consult the Pemivibart EUA Fact Sheet and EUA Frequently Asked Questions for the FDA-authorized conditions under which Pemivibart may be used. CDC is monitoring variants and how commonly they occur to understand if they might affect how well Pemivibart works. The FDA will provide additional updates to the EUA materials, as appropriate, if new information emerges. This is the only preventative option available for COVID-19 for the immunocompromised community, as described above, at the present time.

Pre-exposure prophylaxis helps prevent COVID-19 but does not take the place of vaccination in people who are eligible to receive an updated COVID-19 vaccine. Everyone ages 6 months and older should stay up to date with COVID-19 vaccine.

Actions Healthcare Professionals Can Take:

• Consider early treatment with COVID therapeutics for eligible patients at risk for severe illness. See the IDSA Guidelines on the Treatment and Management of Patients with COVID-19 for treatment recommendations.
• Encourage patients to keep appointments for routine care and adhere to treatment regimens to optimize care of chronic and complex conditions. See the American Academy of Pediatrics (AAP) Guidance on Providing Pediatric Well-Care During COVID-19.
• Encourage patients to complete vaccinations for vaccine-preventable diseases according to CDC immunization schedules.

Recommendations on how to prevent the spread of respiratory viruses when someone is sick can be found in CDC’s Respiratory Virus Guidance.

For CDC’s current recommendations for prevention of COVID-19 in healthcare and community settings see:

• Infection Control Guidance: SARS-CoV-2
• Preventing Respiratory Viruses

Laboratory and radiographic findings

In addition to viral testing, many hospitalized and ambulatory patients will be evaluated with laboratory tests and radiographic studies. Many children will have abnormal vital signs and markers of inflammation when hospitalized for COVID-19¹⁶. A study of over 10,000 hospitalized children found that lower blood pressure, higher heart and respiratory rate, and abnormal markers of inflammation, including D-dimers and ferritin were associated with severe illness in children¹⁶.

Management of illness

Most children with COVID-19 experience asymptomatic or mild to moderate infections that can be managed in the outpatient setting. Outpatient management can include supportive care, consideration of therapeutics in eligible patients at risk for progression to severe illness, and education on measures to decrease the risk of transmission.

Recommendations on clinical management:

• Management Strategies in Children and Adolescents with Mild to Moderate COVID-19 (AAP)

Some children with COVID-19 will experience severe to critical illness that will require hospitalization. Management of severe to critical COVID-19 may include treatment of hypoxemic respiratory failure, acute respiratory distress syndrome (ARDS), septic shock, cardiac dysfunction, thromboembolic disease, hepatic or renal dysfunction, central nervous system disease, and exacerbation of underlying comorbidities. Some, but not all, of the medications authorized for the treatment of severe to critical COVID-19 in adults have been authorized for use in children. More information on therapeutic and clinical management of children with severe to critical COVID-19 can be found in AAP clinical care guidance.

Multisystem Inflammatory Syndrome in Children (MIS-C)

MIS-C generally occurs 2–6 weeks following SARS-CoV-2 infection, and it presents with fever, multisystem organ involvement, and elevated laboratory markers of inflammation. Patients with MIS-C are often critically ill, and studies suggest that more than 50% of patients can require ICU admission^37,38,39. Diagnosing MIS-C can be difficult because the presentation of MIS-C may overlap with that of other conditions, including Kawasaki Disease, toxic shock syndrome, and severe acute COVID-19^38,39.

It is important to consider alternative diagnoses when evaluating children suspected of having MIS-C and to pursue testing to evaluate multisystem involvement as indicated.

Studies suggest that being vaccinated provides protection from MIS-C^41,42, and it is thus important to encourage all families to keep children who are eligible for the COVID-19 vaccine up to date on vaccination⁴¹. Clinical treatment guidelines for MIS-C that describe diagnosis and treatment options have been developed by the American College of Rheumatology, the National Institutes of Health, and the American Academy of Pediatrics.

More information on MIS-C diagnosis and treatment considerations:

• Clinical Overview of Multisystem Inflammatory Syndrome in Children
• Clinical Treatment of Multisystem Inflammatory Syndrome in Children
• MIS-C Interim Guidance (AAP)

Post-COVID Conditions (PCCs)

PCCs are a wide range of new, returning, or ongoing symptoms or health conditions people can experience 4 or more weeks after first being infected with the virus that causes COVID-19. Symptoms can last for extended periods of time. Children experience post-COVID conditions, but they appear to be affected less frequently than adults. Estimates of the proportion of children who experience COVID-19 and later develop post-COVID conditions range widely⁴². Rates of post-COVID conditions seem to increase with age among children and adolescents, and PCCs are found more often in people who had severe acute COVID-19 illness than in people with mild or asymptomatic illness^42,43. Commonly reported symptoms in children can include headache and fatigue, but many organ systems can be involved and some children experience multiple symptoms^42,43. Some studies of post-COVID conditions in children report that symptoms typically do not persist beyond 12 weeks⁴², while others have found that symptoms can linger for longer periods^43,44. Additional research is needed to learn more about symptoms associated with post-COVID conditions in the pediatric population.

References

1. Song JS, Lee J, Kim M, et al. Serial Intervals and Household Transmission of SARS-CoV-2 Omicron Variant, South Korea, 2021. Emerg Infect Dis. Mar 2022;28(3):756-759. doi:10.3201/eid2803.212607
2. Jansen L, Tegomoh B, Lange K, et al. Investigation of a SARS-CoV-2 B.1.1.529 (Omicron) Variant Cluster – Nebraska, November-December 2021. MMWR Morb Mortal Wkly Rep. Dec 31 2021;70(5152):1782-1784. doi:10.15585/mmwr.mm705152e3
3. Zhu F, Ang JY. COVID-19 Infection in Children: Diagnosis and Management. Current Infectious Disease Reports. 2022;24(4):51-62. doi:10.1007/s11908-022-00779-0
4. Siebach MK, Piedimonte G, Ley SH. COVID-19 in childhood: Transmission, clinical presentation, complications and risk factors. Pediatric Pulmonology. 2021;56(6):1342-1356. doi:10.1002/ppul.25344
5. Rubens JH, Akindele NP, Tschudy MM, Sick-Samuels AC. Acute covid-19 and multisystem inflammatory syndrome in children. BMJ. 2021:n385. doi:10.1136/bmj.n385
6. Sharma S, Agha B, Delgado C, et al. Croup Associated With SARS-CoV-2: Pediatric Laryngotracheitis During the Omicron Surge. Journal of the Pediatric Infectious Diseases Society. 2022. doi:10.1093/jpids/piac032
7. Brewster RC, Parsons C, Laird-Gion J, et al. COVID-19–Associated Croup in Children. Pediatrics. 2022;149(6). doi:10.1542/peds.2022-056492
8. Poline J, Gaschignard J, Leblanc C, et al. Systematic Severe Acute Respiratory Syndrome Coronavirus 2 Screening at Hospital Admission in Children: A French Prospective Multicenter Study. Clinical Infectious Diseases. 2021;72(12):2215-2217. doi:10.1093/cid/ciaa1044
9. Martin B, Dewitt PE, Russell S, et al. Characteristics, Outcomes, and Severity Risk Factors Associated With SARS-CoV-2 Infection Among Children in the US National COVID Cohort Collaborative. JAMA Network Open. 2022;5(2):e2143151. doi:10.1001/jamanetworkopen.2021.43151
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11. Woodruff RC, Campbell AP, Taylor CA, et al. Risk Factors for Severe COVID-19 in Children. Pediatrics. 2022;149(1):e2021053418. doi:10.1542/peds.2021-053418
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14. Preston LE, Chevinsky JR, Kompaniyets L, et al. Characteristics and Disease Severity of US Children and Adolescents Diagnosed With COVID-19. JAMA Netw Open. Apr 1 2021;4(4):e215298. doi:10.1001/jamanetworkopen.2021.5298
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16. Marks KJ, Whitaker M, Anglin O, et al. Hospitalizations of Children and Adolescents with Laboratory-Confirmed COVID-19 – COVID-NET, 14 States, July 2021-January 2022. MMWR Morb Mortal Wkly Rep. Feb 18 2022;71(7):271-278. doi:10.15585/mmwr.mm7107e4
17. Marks KJ, Whitaker M, Agathis NT, et al. Hospitalization of Infants and Children Aged 0-4 Years with Laboratory-Confirmed COVID-19 – COVID-NET, 14 States, March 2020-February 2022. MMWR Morb Mortal Wkly Rep. Mar 18 2022;71(11):429-436. doi:10.15585/mmwr.mm7111e2
18. Price AM, Olson SM, Newhams MM, et al. BNT162b2 Protection against the Omicron Variant in Children and Adolescents. N Engl J Med. May 19 2022;386(20):1899-1909. doi:10.1056/NEJMoa2202826
19. Olson SM, Newhams MM, Halasa NB, et al. Effectiveness of Pfizer-BioNTech mRNA Vaccination Against COVID-19 Hospitalization Among Persons Aged 12-18 Years – United States, June-September 2021. MMWR Morb Mortal Wkly Rep. Oct 22 2021;70(42):1483-1488. doi:10.15585/mmwr.mm7042e1
20. Halasa NB, Olson SM, Staat MA, et al. Maternal Vaccination and Risk of Hospitalization for Covid-19 among Infants. N Engl J Med. Jul 14 2022;387(2):109-119. doi:10.1056/NEJMoa2204399
21. Belay ED, Abrams J, Oster ME, et al. Trends in Geographic and Temporal Distribution of US Children With Multisystem Inflammatory Syndrome During the COVID-19 Pandemic. JAMA Pediatr. Aug 1 2021;175(8):837-845. doi:10.1001/jamapediatrics.2021.0630
22. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA. 2021;325(11):1074. doi:10.1001/jama.2021.2091
23. Godfred-Cato S, Abrams JY, Balachandran N, et al. Distinguishing Multisystem Inflammatory Syndrome in Children From COVID-19, Kawasaki Disease and Toxic Shock Syndrome. Pediatr Infect Dis J. Apr 1 2022;41(4):315-323. doi:10.1097/inf.0000000000003449
24. Levy M, Recher M, Hubert H, et al. Multisystem Inflammatory Syndrome in Children by COVID-19 Vaccination Status of Adolescents in France. Jama. Jan 18 2022;327(3):281-283. doi:10.1001/jama.2021.23262
25. Zimmermann P, Pittet LF, Curtis N. How Common is Long COVID in Children and Adolescents? Pediatr Infect Dis J. Dec 1 2021;40(12):e482-e487. doi:10.1097/inf.0000000000003328
26. Kikkenborg Berg S, Dam Nielsen S, Nygaard U, et al. Long COVID symptoms in SARS-CoV-2-positive adolescents and matched controls (LongCOVIDKidsDK): a national, cross-sectional study. The Lancet Child & Adolescent Health. 2022;6(4):240-248. doi:10.1016/s2352-4642(22)00004-9
27. Borch L, Holm M, Knudsen M, Ellermann-Eriksen S, Hagstroem S. Long COVID symptoms and duration in SARS-CoV-2 positive children — a nationwide cohort study. European Journal of Pediatrics. 2022;181(4):1597-1607. doi:10.1007/s00431-021-04345-z
28. Olsen EOM, Roth NM, Aveni K, et al. SARS-CoV-2 infections among neonates born to pregnant people with SARS-CoV-2 infection: Maternal, pregnancy and birth characteristics. Pediatric and Perinatal Epidemiology. 2022. doi:10.1111/ppe.12883