COVID-19 in the Paediatric Population

Original Editor - User:Justin Bryan
Top Contributors - Justin Bryan and Lucinda hampton

Introduction[edit | edit source]

SARS-CoV-2 without background.png

As the SARS-CoV-2 virus (COVID-19) has spread across the globe it has presented unique challenges for every population it has impacted.  While the impacts, symptoms, and long-term implications have been variable, one thing is clear, the virus will continue to affect many aspects of healthcare for some time.  Given this, it is important for providers to recognize the unique ways that COVID-19 impacts the populations they work with.  The following page will focus on the impacts of COVID-19 on the paediatric population, exploring some of the unique aspects that the virus presents in this diverse group of patients.

Characteristics and Clinical Presentation[edit | edit source]

Generally speaking, COVID-19 has presented trends suggesting that it is less severe in the paediatric and adolescent populations (<19 years of age) when compared to adult populations.  That being said, as new variants emerge and spread through both developed and undeveloped countries, reports of complications such as multi-system inflammatory syndrome (MIS-C) have increased in prevalence.[1]

Regardless of the severity of the virus itself, prior and current public response, restrictions, and fear have resulted in widespread interruptions to routine care, including vaccination and annual check-ups, which have profoundly impacted the paediatric and adolescent populations.[1]

Data and Trends from the Early Years of the Pandemic

While much focus was placed on the adult and older adult populations during the early days of the pandemic, multitudes of studies using data collected during this period are now offering intriguing insights as to how the burgeoning virus impacted paediatric patients as well.

Data sets from 2020-2021 largely showed trends suggestive of lower illness severity and mortality among paediatric patients, with these cases accounting for between 1% and 10% of the total cases.  With this, the greatest distribution of infections in children tended to center around school-aged individuals. Worldwide for this period, data from China, Korea, Spain, Italy, and the United States collectively supported this consensus for an age group that included individuals <19 years old.[1][2]

Presentation of COVID-19 in Children and Adolescents

COVID-19 Coronavirus Symptoms.png

Data from the early pandemic suggests signs and symptoms of COVID-19 in younger populations tended to be more variable compared with that of adults. In general, the most common symptoms among children were fever and cough. Other complaints frequently included nausea/vomiting, diarrhea, nasal congestion, and shortness of breath. Asymptomatic presentations also tended to occur more often in children compared to adults. Additionally, the development of more severe cases also tended to be lower among younger individuals, with these cases generally occurring most frequently in the age groups of <1 year and 10-14 years of age.  It is suggested that factors including viral load, and comorbidities such as asthma, immune suppression (i.e. cancer treatment), and congenital heart disease were predictive of increased risk of severe illness or hospitalization.[1][2]

Given the high virulence of SARS-CoV-2, the question has been raised as to why children and adolescents do not represent a higher percentage of cases given that their immune systems are relatively less developed than adults. Several explanations have been suggested for this trend:[2]

  1. ACE2 receptors and protease TMPRSS2 are two components of a specific cell signaling process in the body that the COVID-19 virus exploits. The fact that this signaling pathway is less developed in children and adolescents may inherently reduce the virus' ability to function as optimally as it does in adults
  2. Due to the active development of the immune system at younger ages, the innate immune system is naturally more active in children and adolescents and thus provides greater protection
  3. Given the strong correlation between comorbidities and susceptibility to infection/complications, the presence of fewer comorbidities among children would naturally reduce their risk for infection and severe illness.

Diagnostic Procedures[edit | edit source]

The American Academy of Pediatrics (AAP) has developed suggested guidelines for when children should be tested for COVID-19. Testing is generally similar to that of adults, with tests like polymerase chain reaction (PCR) and antigen testing commonly used to detect a COVID-19 infection in children.[3]

Suggested instances where children should be tested include:[3]

  • Immediately upon presentation of COVID-19 signs and symptoms (i.e. fever, cough, shortness of breath)
  • At least 5 days after contact with a known or suspected positive case of COVID-19
  • When mandated by public health guidelines

A prior confirmed COVID-19 infection in an individual should also be taken into account if that infection occurred within 30-90 days of the current instance where testing is being considered. This is because a recent prior infection can often impact the accuracy of the more current test result. Below are several suggested considerations for this circumstance.[3]

  • Asymptomatic children who have been exposed to a known or suspected COVID-19 positive case AND have previously tested positive within 30 days are NOT recommended to be tested again
  • Children who tested positive for COVID-19 within 30 days and present NEW symptoms should receive an antigen test to detect a new infection. Negative antigen tests should be repeated 48 hrs later to confirm the results
  • Children exposed to a know or suspected COVID-19 positive case AND who have tested positive themselves between 30 and 90 days prior to the exposure may receive antigen testing no less than 5 days after exposure to check for a new infection


Management / Interventions[edit | edit source]

A full explanation of the management and treatment of COVID-19 in children and adolescents is beyond the scope of this resource. However, a brief overview of some current approaches is provided as follows:

Table 1: An overview of select recommendations from the Australian National COVID‐19 Clinical Evidence Taskforce regarding treatment and management of COVID-19 in children.[5]
Treatment Level of Evidence Recommendation
Corticosteroid Medications Conditional Recommendation / low certainty Corticosteroids like dexamethasone may be considered for use in the treatment of acute COVID-19 in children (<19 y/o) who require oxygen support, including mechanical ventilation

Corticosteroids should not be considered for the treatment of acute COVID-19 in children (<19 y/o) who do not require oxygen support

Tocilizumab (Biologic medication) Conditional Recommendation / low certainty Tocilizumab may be considered for use in the treatment of acute COVID-19 in children (<19 y/o) who require oxygen support, including mechanical ventilation

Tocilizumab should be additionally considered especially in the above situation where signs of systemic inflammation are also present

Remdesivir Conditional Recommendation / low certainty Remdesivir is NOT recommended for acute treatment of COVID-19 in children (<19 y/o)
Other Treatments
  • Azithromycin
  • Colchicine
  • Convalescent plasma
  • Hydroxychloroquine
  • Hydroxychloroquine plus azithromycin
  • Interferon‐β‐1a
  • Lopinavir‐ritonavir or interferon‐β‐1a plus lopinavir‐ritonavir
Strong Recommendation / High certainty These treatments are NOT recommended for use in children (<19 y/o). Currently, there is no evidence of the effectiveness of these treatments for acute COVID-19 in adults; this combined with a lack of evidence suggesting anything but a similar outcome for children informs this recommendation.
Venous Thromboembolism Prevention Consensus Recommendation Use standard clinical guidelines and facility/practice recommendations when appropriate for an individual patient, no evidence currently supports any specific changes in the presence of acute COVID-19.
Respiratory therapies (non-invasive) Consensus Recommendation High-flow oxygen therapy may be considered to address hypoxemia or respiratory distress in neonates, children, and adolescents when low-flow oxygen is ineffective

Prone positioning may be considered for use with neonates, children, and adolescents who are cooperative with the intervention, however, close monitoring should be implemented

Invasive respiratory therapies (i.e. mechanical ventilation) Consensus Recommendation For children, neonates, and adolescents with deteriorating conditions that do not respond to non-invasive oxygen therapy, intubation and mechanical ventilation may be considered

Prone positioning may be considered for use with optimized mechanical ventilation in the presence of no contraindication and when close monitoring is in place

Use of a higher PEEP may be considered in the presence of COVID-19 with moderate or severe ARDS and atelectasis with exact values determined by the individual patient

Applied airway pressure recruitment maneuvers may be considered in cases of COVID-19 with hypoxic respiratory failure and severe atelectasis that do not respond to other ventilatory interventions

High frequency oscillatory ventilation (HFOV) should be reserved as a rescue therapy only

In cases of refractory cardiac or respiratory failure in mechanically ventilated patients with COVID-19 receiving optimized care, early referral for Extra Corporeal Membrane Oxygenation (ECMO) may be considered

Invasive respiratory therapies (i.e. mechanical ventilation) Conditional Recommendation / low certainty Continuously infused neuromuscular blockers should NOT be regularly used in patients who are intubated, however, intermittent use may be considered when lung protective ventilation is unachievable

Differential Diagnosis[edit | edit source]

COVID-19 in children and adolescents can often be milder than that of adults, presenting with signs and symptoms similar to other lower respiratory infections including RSV, influenza, and adenovirus. Bacterial and atypical pneumonia may also produce characteristics very close to that of COVID-19. Therefore, the causative agent must be identified in patients who present with symptoms of lower respiratory infection. By identifying the bacteria or virus responsible for a patient's presentation, effective treatments and management can be chosen.[6]

Resources[edit | edit source]

European Centre for Disease Prevention and Control - COVID-19 situation update

United States of America Centers for Disease Control and Prevention - COVID-19

Australian National Clinical Evidence Taskforce COVID-19

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Kammoun, R, and K Masmoudi. Paediatric aspects of COVID-19: An update. Respiratory medicine and research. 2020; 78: 100765.
  2. 2.0 2.1 2.2 Irfan O, Muttalib F, Tang K, Jiang L, Zohra LS, Bhutta Z. Clinical characteristics, treatment and outcomes of paediatric COVID-19: a systematic review and meta-analysis. Archives of Disease in Childhood 2021;106: 440-448.
  3. 3.0 3.1 3.2 American Academy of Pediatrics. COVID-19 Testing Guidance. Available from: (accessed 24/4/2023).
  4. The Royal Children's Hospital Melbourne. A child's guide to hospital: COVID-19 Test. Available from: [Last accessed 6/25/2020]
  5. Navarro DF, Tendal B, Tingay D, Vasilunas N, Anderson L,  Best J, et al. Clinical care of children and adolescents with COVID-19: recommendations from the National COVID-19 Clinical Evidence Taskforce. The Medical Journal of Australia. 2022; 216(5): 255-263.
  6. Carlotti AP, Carvalho WB, Johnston C, Rodriguez IS, Delgado AF. COVID-19 Diagnostic and Management Protocol for Pediatric Patients. Clinics (Sao Paulo, Brazil). 2020; 75(1894): n.p.