Clinical Management of Children Summary
Last Updated: December 28, 2022
Data from the Centers for Disease Control and Prevention demonstrate a lower incidence of SARS-CoV-2 infection, severe disease, and death in children compared with adults.1-4 Although only a small percentage of children with COVID-19 will require medical attention, the percentage of intensive care unit admissions among hospitalized children is comparable to the percentage among hospitalized adults with COVID-19.5-16
Risk factors for severe COVID-19 have been identified through observational studies and meta-analyses primarily conducted before the availability of COVID-19 vaccines. Risk factors include having ≥1 severe comorbid conditions, such as medical complexity with respiratory technology dependence, a neurologic condition resulting in impaired mucociliary clearance, obesity (particularly severe obesity), severe underlying cardiac or pulmonary disease, or severely immunocompromised status. However, pediatric data on risk factors for severe COVID-19 are generally more limited and provide lower certainty than data for adults.
In general, COVID-19 has similar clinical manifestations and disease stages in children and adults, including an early phase driven by viral replication and a late phase that appears to be driven by a dysregulated immune/inflammatory response to SARS-CoV-2 that leads to tissue damage. Respiratory complications in young children that can occur during the early clinical phase include croup and bronchiolitis. In addition, a small number of children who have recovered from acute SARS-CoV-2 infection develop multisystem inflammatory syndrome in children (MIS-C) 2 to 6 weeks after infection. MIS-C is a postinfectious inflammatory condition that can lead to severe organ dysfunction, which is in contrast to COVID-19, the acute, primarily respiratory illness due to infection with SARS-CoV-2.
There are no results available from clinical trials that evaluated treatments for COVID-19 in children, and data from observational studies are limited. Applying adult data from COVID-19 trials to children is a unique challenge because most children experience a mild course of illness with COVID-19. Relative to adults, children with COVID-19 have substantially lower mortality and less need for hospitalization. Because of these differences in epidemiology and disease severity, the effect sizes for children are likely to be smaller than those observed in adults; therefore, to produce a beneficial outcome, the number needed to treat is higher. Collectively, these factors influence the risk versus benefit balance for pharmacologic therapies in children.
In the absence of sufficient clinical trial data on the treatment of children with COVID-19, the COVID-19 Treatment Guidelines Panel’s (the Panel) recommendations for the therapeutic management of children are based largely on adult safety and efficacy data from clinical trials, the child’s risk of disease progression, and expert opinion. In general, the older the child and the more severe the disease, the more reasonable it is to follow treatment recommendations for adult patients with COVID-19.
The Panel’s recommendations for the management of children with COVID-19 or MIS-C are summarized in the tables below. Table 3a provides recommendations for the therapeutic management of nonhospitalized children with COVID-19. The Panel’s recommendations are stratified by age (per the Food and Drug Administration Emergency Use Authorizations) and risk level. See Therapeutic Management of Nonhospitalized Children With COVID-19 for more information. Table 3b includes a framework to help clinicians evaluate the risk for severe COVID-19 based on patient conditions and COVID-19 vaccination status.
The recommendations for hospitalized children in Table 3c are stratified by disease severity. See Therapeutic Management of Hospitalized Children With COVID-19 for more information. Table 3d summarizes the recommendations for the therapeutic management of MIS-C. For the rationale behind these recommendations and supporting data, see Therapeutic Management of Hospitalized Pediatric Patients With Multisystem Inflammatory Syndrome in Children (MIS-C) (With Discussion on Multisystem Inflammatory Syndrome in Adults [MIS-A]).
Table 3a. Therapeutic Management of Nonhospitalized Children With COVID-19
Table 3b. The Panel’s Framework for Assessing the Risk of Progression to Severe COVID-19 Based on Patient Conditions and COVID-19 Vaccination Status
Table 3c. Therapeutic Management of Hospitalized Children With COVID-19
Table 3d. Therapeutic Management of Hospitalized Pediatric Patients With MIS-C
- Centers for Disease Control and Prevention. COVID-19 weekly cases and deaths per 100,000 population by age, race/ethnicity, and sex. 2022. Available at: https://covid.cdc.gov/covid-data-tracker/#demographicsovertime. Accessed July 26, 2022.
- Centers for Disease Control and Prevention. Demographic trends of COVID-19 cases and deaths in the US reported to CDC. 2022. Available at: https://covid.cdc.gov/covid-data-tracker/#demographics. Accessed July 26, 2022.
- Centers for Disease Control and Prevention. COVID-NET laboratory-confirmed COVID-19 hospitalizations. 2022. Available at: https://covid.cdc.gov/covid-data-tracker/#covidnet-hospitalization-network. Accessed July 26, 2022.
- Centers for Disease Control and Prevention. Provisional COVID-19 deaths: focus on ages 0–18 years. 2022. Available at: https://data.cdc.gov/NCHS/Provisional-COVID-19-Deaths-Focus-on-Ages-0-18-Yea/nr4s-juj3. Accessed July 26, 2022.
- Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020;145(6):e20200702. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32179660.
- CDC COVID-19 Response Team. Coronavirus disease 2019 in children—United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(14):422-426. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32271728.
- Cui X, Zhang T, Zheng J, et al. Children with coronavirus disease 2019: a review of demographic, clinical, laboratory, and imaging features in pediatric patients. J Med Virol. 2020;92(9):1501-1510. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32418216.
- Livingston E, Bucher K. Coronavirus disease 2019 (COVID-19) in Italy. JAMA. 2020;323(14):1335. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32181795.
- Tagarro A, Epalza C, Santos M, et al. Screening and severity of coronavirus disease 2019 (COVID-19) in children in Madrid, Spain. JAMA Pediatr. 2020;Published online ahead of print. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32267485.
- DeBiasi RL, Song X, Delaney M, et al. Severe coronavirus disease-2019 in children and young adults in the Washington, DC, metropolitan region. J Pediatr. 2020;223:199-203. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32405091.
- Chao JY, Derespina KR, Herold BC, et al. Clinical characteristics and outcomes of hospitalized and critically ill children and adolescents with coronavirus disease 2019 at a tertiary care medical center in New York City. J Pediatr. 2020;223:14-19. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32407719.
- Swann OV, Holden KA, Turtle L, et al. Clinical characteristics of children and young people admitted to hospital with COVID-19 in United Kingdom: prospective multicentre observational cohort study. BMJ. 2020;370:m3249. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32960186.
- Götzinger F, Santiago-García B, Noguera-Julián A, et al. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health. 2020;4(9):653-661. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32593339.
- Shi DS, Whitaker M, Marks KJ, et al. Hospitalizations of children aged 5–11 years with laboratory-confirmed COVID-19—COVID-NET, 14 states, March 2020–February 2022. MMWR Morb Mortal Wkly Rep. 2022;71(16):574-581. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35446827.
- Siegel DA, Reses HE, Cool AJ, et al. Trends in COVID-19 cases, emergency department visits, and hospital admissions among children and adolescents aged 0–17 years—United States, August 2020–August 2021. MMWR Morb Mortal Wkly Rep. 2021;70(36):1249-1254. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34499628.
- Marks KJ, Whitaker M, Anglin O, et al. Hospitalizations of children and adolescents with laboratory-confirmed COVID-19—COVID-NET, 14 states, July 2021–January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(7):271-278. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35176003.