Skip to Main Content

COVID Impacts

Detailed information and resources on the long-term health consequences of COVID-19 infection and the broad social impacts of the COVID-19 pandemic

Clinical Manifestations of COVID-19 Infection in Children

Clinical Spectrum of COVID-19 Disease in Children

The clinical spectrum of SARS-CoV-2 infections in children ranges from asymptomatic to life-threatening. Asymptomatic infection is common in children. In a 2020 systematic review of 18 reviews of symptoms and signs in children <20 years of age with documented SARS-CoV-2 infection, the proportion of asymptomatic infections ranged from 15 to 42 percent.

In a retrospective review of electronic health records of 82,798 United States children <18 years of age with laboratory-confirmed SARS-CoV-2 infection between March 2020 and December 2021, 66 percent were asymptomatic, 27 percent were mild (COVID-19-related symptoms), 5 percent were moderate (moderately severe COVID-19-related condition such as pneumonia, gastroenteritis, dehydration), and 2 percent were severe (unstable COVID-19-related condition, requiring intensive care unit [ICU] admission or mechanical ventilation).

Among children with COVID-19 admitted to the ICU, the severity appears to be similar to that of influenza. In a multicenter study comparing children admitted to the ICU with influenza and children admitted to the ICU with COVID-19, approximately 30 percent in each group required mechanical ventilation, 20 percent required vasopressor support, and 2 to 3 percent required extracorporeal membrane oxygenation.

Why severe COVID-19 appears to be less frequent in children than in adults is unclear. One possibility is that children have a less-intense immune response to the virus than adults; cytokine release syndrome is thought to be important in the pathogenesis of severe COVID-19 infections. Other possibilities include: viral interference in the respiratory tract of young children, which may lead to a lower SARS-CoV-2 viral load; different expression of the angiotensin converting enzyme 2 receptor (the receptor for SARS-CoV-2) in the respiratory tracts of children and adults; pre-existing cross-reactive antibody; a vigorous early mucosal immune response; protective off-target effects of live vaccines; relatively healthier blood vessels in children than in adults; developmental differences in adaptive immune responses during the first years of life; and age-related differences in the nasopharyngeal microbiome.

Commonly Reported Symptoms in Children

The clinical presentation of symptomatic SARS-CoV-2 infection in children is variable and overlaps with other clinical syndromes (eg, pneumonia, bronchiolitis, croup, e-cigarette or vaping product use-associated lung injury, gastroenteritis). The clinical presentation is similar in immunocompetent and immunocompromised children.

In case surveillance in the United States, commonly reported symptoms among children and adolescents:

  • Fever
  • Cough
  • Shortness of breath
  • Myalgia (muscle aches)
  • Rhinorrhea (runny nose)
  • Sore throat
  • Headache
  • Nausea/vomiting
  • Abdominal pain
  • Diarrhea
  • Loss of smell or taste (in nonverbal children, this may manifest as solid food aversion or refusal)

COVID-19 Infections in the Omicron Era

Beginning in early 2022, with the invasion of the Omicron variant, doctors began noting an increase in the number of children presenting to offices and emergency rooms with croup, and being positive for COVID-19. Unlike earlier versions of COVID-19, Omicron tends to settle higher up in the respiratory tract, rather than in the lungs, leading to an increase in the number of children developing the trademark barking cough associated with croup, which is most common among children between the ages of six months and three years.

Croup is an infection of the upper airway, which hampers breathing and causes the barking cough. The cough and other symptoms of croup are the result of swelling around the voice box, windpipe and bronchial tubes. In addition to the cough, taking a breath often sounds like a high-pitched whistling sound called stridor. Croup cases are most common in the fall and winter months.

In addition to the barking-like cough, other symptoms of croup are fever, hoarse voice and labored breathing. Symptoms typically last between 3 to 5 days. Humidifiers can help ease symptoms, but if the coughing or inflammation gets worse, steroids or even a trip to the emergency department may be required.

Multisystem Inflammatory Syndrome in Children (MIS-C)

Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition associated with SARS-CoV-2 (the virus that causes COVID-19), that usually occurs 2-6 weeks after a child is infected with SARS-CoV-2.

The child’s SARS-CoV-2 infection may be very mild or have no symptoms at all and may go unrecognized. MIS-C causes different internal and external body parts to become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal tract. MIS-C can be serious, even deadly, but most children who are diagnosed with this condition get better with medical care.

The Council of State and Territorial Epidemiologists (CSTE) and CDC have developed a new CSTE/CDC MIS-C surveillance case definition and case report forms to be used starting January 1, 2023.

Signs & Symptoms of MIS
Children with MIS experience:
  • Ongoing fever PLUS more than one of the following:
    • Stomach pain
    • Bloodshot eyes
    • Diarrhea
    • Dizziness or lightheadedness (signs of low blood pressure)
    • Skin rash
    • Vomiting
When to seek emergency care:
  • Trouble breathing
  • Pain or pressure in the chest that does not go away
  • Confusion or unusual behavior
  • Severe abdominal pain
  • Inability to wake or stay awake
  • Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone

COVID-19 Data in Children

U.S. Children and COVID-19 State Level Data Report

The report was created in the early months of the COVID-19 pandemic to measure how COVID-19 was affecting children in the United States. The CDC had begun providing national data on COVID-19 cases, but timely, regular data on pediatric cases were not available. Thus, we turned to data provided by states and territories and began to collect information from their web sites for the most current pediatric data. By compiling this information we could track the number of child cases weekly, as well as provide publicly reported case numbers for children at the state level.

Final Summary

On May 11, 2023, the United States ended the Public Health Emergency (PHE) that was declared over three years ago to organize government resources and establish policies needed to respond to the COVID-19 pandemic. After three years of weekly reporting on the number of child COVID-19 cases in the United States, the American Academy of Pediatrics (AAP) and the Children’s Hospital Association (CHA) will be sunsetting the weekly state COVID-19 reports.

As of May 11, 2023, nearly 15.6 million children were reported to have tested positive for COVID-19 since the onset of the pandemic according to available state reports. Over the past three years, the highest number of child cases reported in a week was over 1.1 million for the week ending January 20, 2022. Since the pandemic began, children represented 17.9% of total cumulated cases. The portion of reported cases that were children ranged from a low of 2.0% the week ending April 16, 2020 to a high of 28.9% the week ending September 9, 2021 (children, under age 18, make up 22.2% of the US population).

Cumulative Number of Child COVID-19 Cases*
  • 15,594,079 total child COVID-19 cases reported, and children represented 17.9% (15,594,079/86,881,822) of all cases
  • Overall rate: 20,718 cases per 100,000 children in the population

Provisional COVID-19 Deaths: Focus on Ages 0-18 Years

Data from the National Center for Health Statistics (NCHS) Deaths involving coronavirus disease 2019 (COVID-19) with a focus on ages 0-18 years in the United States.

Effective June 28, 2023, this dataset will no longer be updated. Similar data are accessible from CDC WONDER (

Highlighted Literature