Important update: Healthcare facilities
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UPDATE
Given new evidence on the B.1.617.2 (Delta) variant, CDC has updated the guidance for fully vaccinated people. CDC recommends universal indoor masking for all teachers, staff, students, and visitors to K-12 schools, regardless of vaccination status. Children should return to full-time in-person learning in the fall with layered prevention strategies in place.
UPDATE
The White House announced that vaccines will be required for international travelers coming into the United States, with an effective date of November 8, 2021. For purposes of entry into the United States, vaccines accepted will include FDA approved or authorized and WHO Emergency Use Listing vaccines. More information is available here.
UPDATE
Travel requirements to enter the United States are changing, starting November 8, 2021. More information is available here.

Information for Pediatric Healthcare Providers

Information for Pediatric Healthcare Providers
Updated Oct. 19, 2022

Purpose

This content provides clinicians and public health professionals with key information and evidence for clinical considerations when diagnosing and managing pediatric patients infected with SARS-CoV-2, the virus that causes COVID-19. For evidence-based treatment recommendations for COVID-19, visit the National Institutes of Health (NIH) COVID-19 Treatment Guidelines prepared by the COVID-19 Treatment Guidelines Panel. Also see the American Academy of Pediatrics (AAP) Critical Updates on COVID-19 and the Centers for Disease Control and Prevention’s (CDC’s) Variants of the Virus and Vaccines for COVID-19.

Summary of Recent Changes

  • Revisions were made on October 17, 2022, to include new information about COVID-19 relevant for pediatric healthcare providers.

View Previous Updates

Incidence

The epidemiology of COVID-19 in the pediatric population has been challenging to establish for several reasons, including the high prevalence of asymptomatic infection and differences in testing rates between children and adults1,2. Studies have found that compared with adults, children may have similar or higher incidence rates of SARS-CoV-2 infection but more frequently experience asymptomatic infection or less severe symptoms3,4,5.

Visit the Pediatric Data page of the COVID Data Tracker to view updated case trends and other epidemiological data related to children and adults, including seroprevalence data.

Incubation Period and Clinical Presentation

The incubation period for COVID-19 is thought to extend to 14 days, but studies suggest that incubation periods may differ by variant of the virus.

A study conducted during high levels of Delta variant transmission reported a mean incubation period of 4.3 days, but the mean incubation periods of other variants, including Alpha and Beta, was 5 days6. Studies performed during high levels of Omicron variant transmission reported a median incubation period of 3 ­- 4 days7,8.

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 diarrhea9,10,11,12. 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 croup13,14.

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 challenging15. Testing for SARS-CoV-2 should be considered, even in children with mild symptoms.

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 death16. 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-1917,18,19,20, and having more than one pre-existing comorbidity is associated with an increased risk of severe illness18,21.

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 cases22. Similarly, a study of hospitalization rates among children aged 0-17 years found that COVID-19–associated hospitalization rates among children and adolescents during the Omicron period were four times as high as rates during the peak of the Delta period, and children aged 0-4 years experienced the largest increase in hospitalization rates23. 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 factors24,17,19. Adolescents aged 12-17 years also have experienced higher COVID-19–associated hospitalization rates compared to children aged 5-11 years17.

In addition to individual risk factors, the COVID-19 variant that is circulating at the time of infection could have an impact on disease severity. Compared to prior periods, studies among children aged 0-17 years conducted during the Delta variant predominant period found increased rates of hospitalization25,26. Studies that compared the Delta- to the Omicron- predominant period found increased rates of hospitalization during the Omicron-predominant period, but pediatric patients experienced less severe disease during the Omicron-predominant period than in previous waves23,27,28.

Studies have found that vaccination is effective at reducing risk of hospitalization29 in children and adolescents and critical illness in adolescents29,30. A study conducted during Omicron predominance found that the effectiveness of a 2-dose mRNA vaccine against symptomatic infection decreased rapidly, and among adolescents, vaccine effectiveness increased after a booster dose31. 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 age32. 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.

Some children who are at risk for severe disease may benefit from early COVID-19 testing and antiviral treatment; others may be eligible for pre-exposure prophylaxis.

Information on Testing Strategies:

Information on Antiviral Treatment Options:

Actions Healthcare Professionals Can Take

Testing, Diagnosis, and Recommendations for Isolation

Testing of Children

Viral tests, including nucleic acid amplification tests (NAATs) and antigen tests, are recommended to diagnose acute infection with SARS-CoV-2. Testing is important to identify infection and prevent transmission of COVID-19. People who have symptoms of COVID-19 and close contacts of people with COVID-19 should be tested. More information on testing guidelines and strategies can be found at the CDC’s Overview of Testing for SARS-CoV-2, the Virus that Causes COVID-19 webpage and the Food and Drug Administration’s (FDA’s) recommendations for At-Home COVID-19 Antigen Testing. Recommendations on isolation can be found at the CDC’s Interim Guidance on Ending Isolation and Precautions for People with COVID-19 and the Isolation and Precautions for People with COVID-19 webpage.

Testing of Newborns

Most infants born to people with COVID-19 do not test positive for the virus at birth33, so the American Academy of Pediatrics recommends testing healthy infants born to people infected with SARS-CoV-2 at least once before hospital discharge, and as close to discharge as practical. Newborns with signs and symptoms of COVID-19 should be tested for SARS-CoV-2 immediately.

Testing in Schools

Schools may offer diagnostic testing for students and staff with symptoms of COVID-19 or who were exposed to someone with COVID-19. When COVID-19 community levels are high, schools can consider implementing screening testing for students and staff, for high-risk activities (for example, close contact sports, band, choir, theater), and at key times in the year, for example before/after large events (such as prom, tournaments, group travel) and when returning from breaks (such as, holidays, spring break, at the beginning of the school year). Testing, along with COVID-19 vaccination, proper masking, and other mitigation strategies can help prevent transmission among students, staff, and family members. More information on testing and other recommendations for prevention of COVID-19 in the school setting can be found on the CDC’s Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning webpage.

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.

Chest radiographs and computed tomography (CT) images of children with COVID-19 are frequently normal34,35, but chest radiographs may demonstrate patchy infiltrates or opacities34,36.  The most common CT finding is patchy ground-glass opacification35.

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:

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 the NIH COVID-19 Treatment Guidelines.

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 admission37,38,39. 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-1938,39.

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-C41,42, 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. For information to assist providers in speaking with patients and families about MIS-C, see Talking with Families and Caregivers.

More information on MIS-C diagnosis and treatment considerations:

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 illness42,43.  Commonly reported symptoms in children can include headache and fatigue, but many organ systems can be involved and some children experience multiple symptoms42,43.  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 periods43,44. Additional research is needed to learn more about symptoms associated with post-COVID conditions in the pediatric population.

When caring for patients with post-COVID conditions, clinicians can consult CDC’s General Clinical Considerations for suggestions on initial diagnostic and follow-up evaluation.

More information on PCCs:

Considerations for Routine Pediatric Care During the COVID-19 Pandemic

During 2020–2021, there were significant declines in outpatient pediatric visits and well-child check-ups, and many children have missed recommended screenings and vaccinations45,46,47, 48.

The CDC recommends Healthcare providers use the Catch-up Immunization schedule to immunize children who are more than one month behind on immunizations, and the American Academy of Pediatrics (AAP) provides clinical Guidance on Providing Pediatric Well-Care During COVID-19. For general guidance on pediatric preventive care, see the Bright Futures/AAP’s Periodicity Schedule for Recommendations for Preventive Pediatric Health Care and screenings by age and the CDC’s Immunization Schedule for ages 18 years or younger.

References

Previous Updates