The COVID-19 pandemic has impacted people of all ages, but its effects on children have been particularly concerning. Early in the pandemic, there were hopes that SARS-CoV-2, the virus that causes COVID-19, would spare children or only cause mild illness. However, it soon became clear that while children are less likely to develop severe illness compared to adults, COVID-19 can still result in hospitalization and death in the pediatric population. Understanding the severity of COVID-19 in children is critical for public health strategies and ensuring the wellbeing of our youngest generations.
How does COVID-19 affect children compared to adults?
Several studies have shown that children, particularly those under the age of 10, are less susceptible to SARS-CoV-2 infection and develop less severe symptoms compared to adults. The exact reasons are still under investigation, but likely relate to differences in ACE2 receptors, immune function, and underslyying health conditions. Some key differences between COVID-19 manifestations in children versus adults include:
– Infection risk: Children are estimated to be half as likely to acquire infection compared to adults. In household transmission studies, adults were much more likely to be the index case that introduced SARS-CoV-2 into a household.
– Asymptomatic infection: Approximately 25-35% of children with confirmed SARS-CoV-2 infection are asymptomatic, compared to only about 10% of adults.
– Symptom type: Children experience fever, cough, and shortness of breath less commonly than adult patients. They are more likely to present initially with non-respiratory symptoms like abdominal pain, rash, and conjunctivitis.
– Respiratory complications: Only about 1-5% of infected children develop acute respiratory distress syndrome or require ICU care for respiratory support, compared to 10-15% of adults.
– Multi-system inflammatory syndrome: A small percentage of children develop MIS-C, a post-infectious hyperinflammatory condition, while this is very rarely seen in adults.
– Mortality: Death from COVID-19 is extremely rare in children at 0.01-0.03%, versus around 1-3% overall population mortality. Children account for less than 0.2% of total recorded COVID-19 deaths in the US.
So while children are susceptible to SARS-CoV-2, they tend to get less sick overall compared to adults in terms of severity of acute illness, risk of respiratory complications, and death. However, severe outcomes can still occur in children, especially those with underlying medical conditions.
How many children have been affected by COVID-19?
By official counts, relatively few children have contracted COVID-19 compared to adults. However, getting precise estimates is challenging due to limited testing, especially early in the pandemic. According to the American Academy of Pediatrics, over 17 million child COVID-19 cases had been reported in the United States as of November 2022. This represents about 1 in 6 of total reported cases, while children make up 22% of the US population. Studies estimate the true number of infections among children may be double the reported figure.
Globally, UNICEF estimates about 13% of total reported cases have been among children and adolescents under 20 years old. However, due to limited testing, the actual proportion is likely higher. Regional differences have been observed in the demographics of pediatric COVID-19. For example, children accounted for only 2% of cases in China versus 22% in Spain. Ongoing surveillance will provide better clarity on the burden of pediatric COVID-19.
Cumulative child COVID-19 cases and deaths in the US
| Total child COVID-19 cases | Over 17 million |
| Total child COVID-19 deaths | Over 1,800 |
How many children have been hospitalized or died from COVID-19?
While risk of severe illness is lower in children, COVID-19 does result in concerning rates of hospitalization and death among the pediatric population.
US data on severe pediatric COVID-19 outcomes
– Over 117,000 child COVID-19 hospitalizations have been reported in the US as of November 2022. Children represent about 1.5-4% of total reported hospitalizations.
– 1-1.5% of child COVID-19 cases result in hospitalization compared to 5-10% of adult cases.
– 0.4-2% of hospitalized children require intensive care for COVID-19.
– Death has occurred in 0.01-0.5% of child COVID-19 cases with over 1,800 confirmed pediatric deaths.
– Among hospitalized children, those under 1 year old have had the highest risk of requiring intensive care and death.
– Up to 80% of children who died had underlying conditions such as chronic lung disease, obesity, and neurological or developmental disorders.
International data on pediatric COVID-19 mortality
Globally, a small percentage of total COVID-19 deaths are among those under 20 years old:
| Location | COVID-19 deaths under age 20 | Percent of total deaths |
| United States | 1,755 | 0.17% |
| United Kingdom | 182 | 0.03% |
| France | 24 | 0.05% |
| Brazil | 2,978 | 0.76% |
| India | 655 | 0.54% |
So while pediatric deaths are very rare overall, thousands of children have still lost their lives to COVID-19 worldwide.
How does Omicron affect children?
The emergence of the Omicron variant in late 2021 brought new questions about COVID-19 severity in children. Early data from South Africa showed hospitalization rates among children were lower with Omicron infection compared to previous waves. However, the overall number of pediatric admissions rose due to the sheer volume of Omicron cases.
In the US, COVID-19 hospitalizations among children hit record highs during the Omicron surge in January 2022 but have since declined. Pediatric intensive care unit admissions and ventilator use was less common compared to the Delta wave, suggesting milder illness. However, very young children and those with underlying conditions continued to be at highest risk for severe complications.
Experts believe Omicron causes less severe disease across all ages due to different virologic characteristics compared to prior variants. But it is still too soon to assume Omicron is uniformly mild in children. Close monitoring of pediatric hospitalizations and deaths remains critical.
How long can symptoms last in children?
Most children with COVID-19 start to recover within 1-2 weeks, but some experience persistent symptoms lasting months.
– In a UK study, 4.4% of children had symptoms lasting over 28 days. Common long-lasting symptoms included fatigue, headache, loss of smell, and sore throat.
– Post-COVID conditions like brain fog, chronic fatigue, and respiratory problems have been reported in children, but appear to be less common than in adults.
– Long COVID occurs more often in children who experienced severe acute illness, but can also develop after mild or even asymptomatic infection.
– Teens appear to be at higher risk of persistent symptoms compared to younger children.
– Most pediatric patients with long COVID fully recover within 3-6 months, but a small percentage have symptoms lasting over a year.
So while COVID-19 is usually transient in children, prolonged symptoms are possible even after mild disease. Monitoring pediatric data on long COVID will be important for understanding the full scope of COVID-19 impacts on children.
What role do underlying conditions play in severe COVID-19 among children?
Underlying medical conditions significantly increase a child’s risk of severe COVID-19 complications and death. Some of the most important risk factors include:
– Asthma: Having moderate to severe asthma is linked to a 3-fold higher risk of severe COVID-19 among children.
– Obesity: Obesity is present in about 25-35% of hospitalized children with COVID-19 and is associated with greater risk of ICU admission, ventilator support, and death.
– Neurological disorders: Conditions like seizures, cerebral palsy, and developmental delays increase COVID-19 severity in children.
– Immunosuppression: Those with weakened immune systems due to chemotherapy, organ transplant, or HIV have heightened vulnerability to COVID-19.
– Diabetes: Poorly controlled blood sugar in children with diabetes poses up to a 4-fold increased risk of severe COVID-19.
– Prematurity: Infants born prematurely, especially those with chronic lung disease, are among those at highest risk for COVID-19 mortality.
– Congenital heart disease: Heart abnormalities in children significantly increase COVID-19 severity.
So while most infected children develop mild illness, those with underlying conditions are far more likely to become critically ill. Tracking comorbidities in pediatric COVID-19 remains key.
How do COVID-19 vaccines affect children?
COVID-19 vaccines have been demonstrated to be very safe and effective at protecting children from COVID-19.
– No serious safety concerns were identified in clinical trials of mRNA vaccines (Pfizer/BioNTech, Moderna) in thousands of adolescents and children.
– Myocarditis risk following vaccination is slightly elevated in young males but still very rare, and COVID-19 itself poses a greater myocarditis risk.
– mRNA vaccines were 91% effective at preventing symptomatic COVID-19 in the Pfizer adolescent trial. Effectiveness was high against Delta and Omicron variants.
– Over 14 million children have received at least one dose of a COVID-19 vaccine in the US to date. Real world safety monitoring has confirmed their safety profile.
– Unvaccinated children age 5-11 were hospitalized at 8 times the rate of fully vaccinated children during Omicron, highlighting vaccine protection.
– Vaccination provides broader benefits like reducing school interruptions and MIS-C risk.
While children are less vulnerable to COVID-19 overall, vaccination is still recommended for added protection and benefits at both individual and societal levels. Ongoing monitoring will continue to ensure safety across all pediatric age groups.
Conclusion
While children with COVID-19 are much less likely to develop severe illness and die compared to adults, serious complications and deaths do still occur. This underscores the importance of continued data tracking, safety measures, and vaccination to protect children from COVID-19. However, the relative mildness of infection in most pediatric cases provides some reassurance that children are significantly less affected by this disease. Ongoing research on post-COVID conditions, the role of comorbidities, and other factors will shed more light on the unique impacts of this pandemic on children.