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Coronavirus Disease 2019 (COVID-19) in Children

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 22% of the US population, approximately 14% of all cases of COVID-19 reported to the Centers for Disease Control and Prevention (CDC) were among children (as of September 27, 2021).
 Most cases in children are mild, and treatment consists of supportive care. 

The American Academy of Pediatrics (AAP) reports children represent 16.0% of all cases in the 49 states reporting by age; over 5.7 million children have tested positive in the United States since the onset of the pandemic as of September 23, 2021. This represents an overall rate of 7,607 cases per 100,000 children. During the 2-week period of September 9 to September 23, 2021, there was an 8% increase in cumulated number of children who tested positive, representing 432,843 new cases. In the week from September 16 to September 23, 2021, cases in children numbered 206,864, representing 26.7% of the new weekly cases. Children were 1.6-4.1% of total reported hospitalizations, and between 0.1-2.0% of all child COVID-19 cases resulted in hospitalization.

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.
 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)

Diagnosis

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.

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

Management

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.
 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.
 The FDA expanded the EUA to include use in all hospitalized patients with confirmed or suspected COVID-19 disease, regardless of oxygen status.
 

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.

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