COVID-19 in Pediatrics

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Our understanding of the spectrum of the COVID-19 illness in adults is limited and evolving. This same admonition applies to children where information is more sparse and dynamic.  Here is what we know.

Vertical transmission does occur but not readily. A Chinese study of nine infants demonstrated no transmission of COVID-19 from the mother to the fetus in the 3rd trimester. However, all of the children were delivered by Cesarean. The same study found no virus in cord blood, amniotic fluid, breast milk or infants’ throats. A second study in China found about a 10% transmission rate from mother to infant (3 of 33 births).  All of the infants did well clinically ( JAMA Pediatr. March 26, 2020. doi:10.1001/jamapediatrics.2020.0878) 

Children age 0-18 years old are just as susceptible to COVID-19 but, in general, when infected, are less symptomatic. In a large report from China in late February, only 2% of infections were in individuals younger than 20 years old.  This number is likely unrepresentative since this is a retrospective study and healthy children were not likely to be tested.  Of children infected, 13% are entirely asymptomatic; again, the true number is no doubt higher. Over 90% of children are asymptomatic or have mild or moderate symptoms.

When children do have symptoms they are

  • Cough-49%
  • Pharyngeal erythema-46%
  • Fever-42% (>39C in 9%)
  • Diarrhea-9%
  • Vomiting, rhinorrhea, congestion
  • 16% were asymptomatic but this number is likely higher since individuals with symptoms are more likely to get tested.
  • (NEJM March 18, 2020 DOI: 10.1056/NEJMc2005073

Children < 1 year are more likely to have severe or critical disease (10%), those 1-5 years 7.5%, and those age 6-16 3-4%.  Only 0.6% went on to develop ARDS or multisystem organ failure.  Furthermore, the case fatality from COVID-19 in individuals 0-19 years of age was less than 0.2%.  As one would expect, underlaying disease makes serious COVID-19 more likely.  It is also of note that there is prolonged sheading of virus in children both from the respiratory and GI track (fecal).

COVID-19 Disease and Kawasaki disease

There have been several cases Kawasaki disease/an overlap syndrome of toxic shock and Kawasaki syndrome in children with COVID-19.  Reports note fever, conjunctivitis, a polymorphous, blanching rash, tongue involvement and swelling of hands and feet.

The Pediatric Intensive Care Society from Britain has alerted providers to be vigilant in identifying these patients and note that they often have GI symptoms, abdominal pain, myocarditis and coronary artery findings consistent with Kawasaki Disease. Lab abnormalities include an elevated troponin, and elevated CRP and sedimentation rate.  Of note, some of these patients have been COVID-19 negative.

The classic constellation of symptoms for Kawasaki disease include: Fever for at least 5 days, Mucositis, Conjunctivitis, Polymorphous rash, Distal extremity edema, and Lymphadenopathy (which is commonly absent).  An incomplete syndrome is common.  There may be accompanying carditis.  The take home message for clinicians is to realize this association with COVID-19 likely exists and to have a low threshold for referral for a higher level of care.  

Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki disease: novel virus and novel case. Hosp Pediatr. 2020; doi: 10.1542/hpeds.2020-0123


Although the initial mode of transmission of COVID-19 was associated with a seafood market, person-to-person spread by respiratory droplet is the main mode of transmission. Since they are often asymptomatic, infected children can be a great risk to the community. They are unintentionally super-spreaders of the virus. Their awareness of the routine or commonsense environmental cleaning and disinfection is less optimal and unlikely to be followed, due to their developmental stage of comprehension.

Protecting children and the community at large is a paramount task of adults who can encourage children  to help stop the spread of COVID-19 by diligently teaching them to do the same things everyone should do to stay healthy.

  • Diligent observation of hand washing or use of hand sanitizer
  • Respiratory hygiene or (covering the cough or sneezing)
  • Avoiding touching the face
  • Cleaning and disinfecting the high touch-touch surfaces and washable plush toys
  • Avoiding crowds
  • Staying home when sick

These routine skills and practices are not instinctive. Patience and perseverance are the key to teach children these difficult but critical recommendations for the safety of everyone.

Education is another sphere that impacted by the COVID-19 epidemic. Many schools and group activities have ended or have been put on hold. 

Officials and expert strongly recommend mitigating against the possible negative impacts on children’s learning and wellbeing during school closure. Parents and other caregivers need to have solid plans in place to ensure the continuity of learning, including remote learning options and access to essential services for children. United Nations Internation Children’s Emergency Fund (UNICEF) has issued guidance with a key messages and actions for COVID-19 prevention and control in school. The new guidance also offers helpful tips and checklists for parents and caregivers, as well as children and students themselves.  They can be found here.

Often, a child’s most reliable source of nutrition is a school lunch or other meal.  Food insecurity may be an issue with schools closed.  Providers seeing all patients should enquire about this and help to locate resources in the community that can help with food supplementation.

The American Academy of Pediatrics maintains a website specifically aimed at those caring for children during this pandemic. It can be found here.

Another pediatric specific website is maintained by the Red Book. It can be found here.

Children and young people are global citizens, powerful agents of change and the next generation of caregivers, scientists, and doctors. Any crisis (COVID-19 is a crisis) presents the opportunity to help them learn, cultivate compassion and increase resilience while building a safe and more caring community.

Bi, Q et al.   Epidemiology and Transmission of COVID-19 in Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts,,  Accessed 23 March 2020

Cruz A, Zeichner S. COVID-19 in children: initial characterization of the pediatric disease. Pediatrics. 2020; doi: 10.1542/peds.2020-0834

Dong Y, Mo X, Hu, Y, et al. [Epidemiology of COVID-19 among children in China]. IN PRESS this issue Pediatrics.

UNICEF. Guidance for COVID-19 Prevention and Control in Schools.  Accessed 23 March 2020

WHO.  Key Messages and Actions for COVID-19 Prevention and Control in Schools. Accessed 20 March 2020


Tameem Shoukih, MD

Assistant Professor of Emergency Medicine, University of Iowa