July 22, 2020 -- Since the beginning of the pandemic, parents have been reassured that if their children do get COVID-19, they’re unlikely to get really sick. And much of the data continues to support that idea. But as the pandemic spreads widely in many states and the beginning of the school year approaches, it’s only natural to wonder if your child is really at risk – and if they are, does that put your whole family at risk, too?

“This is a terrible, terrible illness,” says Lawrence Kleinman, MD, a professor and vice chair of the pediatrics department at Rutgers Robert Wood Johnson Medical School. “It began with a myth, and that myth has had persistent and troubling longevity. It’s in our consciousness that kids don’t get as sick, or it doesn’t matter as much.”

What the Numbers Show

According to the CDC, only 6.6% of all confirmed cases in the U.S. have been in children under 18 years old. Regionally, though, the numbers look different. According to an analysis by Bloomberg News, in places where the virus is surging, children account for 10% or more of cases.

Figures from Florida’s Department of Health show that as of July 9, 31% of all children tested in the state were positive for the coronavirus. But that doesn’t necessarily mean the virus is on the rise among kids.

“A high positivity rate means you’re not testing enough,” says Beth Pathak, PhD, an epidemiologist and co-founder of The COVKID Project, which seeks to track all pediatric cases in the U.S. “The World Health Organization recommends that testing and community control of the virus be expanded until the test positivity rate is less than 5%.” When nearly one-third of kids’ tests come back positive, it indicates that tests are only given to children who are showing symptoms, Pathak explains. Since we know many kids have mild or no symptoms at all, there must be considerably more, untested cases in the community.

The COVKID Project’s nationwide total shows nearly 300,000 confirmed cases are aged 0-19. But by basing their models on detailed data from China, they estimated that more than 1.9 million children have already caught the virus. That’s only 2.6% of all the kids in this country.

“We found that for every 2,381 kids who get infected—not sick, just testing positive for the virus—one child will become critically ill and need to be admitted to the ICU,” says Pathak.

Those may sound like low odds, but there are 74 million children in the United States. If we reach 10% of children infected, The COVKID Project says we could see 20,000 hospitalized. And by the time we approach herd immunity, that number would be closer to 120,000 children so severely ill they need to be in the hospital.

“Childhood cancer is rare but that doesn’t mean it’s no big deal,” says Pathak. “We need to talk about COVID in a way that doesn’t minimize the losses, and also doesn’t exaggerate the risk.”

What COVID Looks Like in Kids

It does appear that children are less likely to develop symptoms than adults. A study in the journal Nature Medicine looked at data from six different countries. It found that when children are infected, only one in five develops symptoms. Compare that to people over 70, who showed symptoms nearly 70% of the time.

As far as symptoms go, COVID in children looks similar to the disease in adults. The most common ones include:

Children may have more diarrhea and other stomach issues than adults, and they may be more likely to have fatigue as a primary symptom, says Katherine Connor, MD, assistant professor of pediatrics at Johns Hopkins University School of Medicine.

“The big difference is that kids seem to get a milder illness, often with no symptoms,” she says. Of the more than 140,000 deaths due to COVID in this country, 75 have been in children, says The COVKID Project. Fewer than 1,000 have needed the ICU, according to the available data.

Among children who developed a severe case of COVID, several risk factors have emerged. Those include obesity, diabetes, asthma and chronic lung disease, having a suppressed immune system, congenital heart disease, and serious genetic, neurologic, or metabolic disorders. But Kleinman cautions against being too relaxed if your child doesn’t have any of those issues: “Of those in the ICU, 17% had nothing. So it doesn’t mean the other side is safe,” he says.

Doctors can’t yet explain why so many infected children don’t show symptoms. E.R. Chulie Ulloa, MD, MSc, a pediatric infectious disease specialist and assistant professor at the UC Irvine School of Medicine, says researchers are investigating several possibilities. They include differences in the respiratory tract or the immune system, viral interference—the idea that kids get so many other viruses, they may be blocking the novel coronavirus—and even ordinary childhood vaccines.

“There's been some data to suggest that immunization to other common childhood infections confers a kind of cross-protection,” Ulloa says.

Multisystem Inflammatory Syndrome in Children (MIS-C)

This syndrome made headlines when it first began to appear among children, several weeks after they’d had the virus—and sometimes, even when they hadn’t. But it’s proven to be extremely rare. So far, fewer than 350 cases have been reported in the U.S. Six children have died from it.

“The main thing to be aware of: You should be talking to your healthcare provider earlier than you typically would,” says Connor. “Seasoned parents usually wait out a fever or stomachache for a few days before calling the pediatrician. But because the increased risk is still unfolding, you should reach out to your healthcare provider immediately. They can provide specific guidance for your child.”

Symptoms of MIS-C vary slightly from COVID-19:

“The symptoms aren’t subtle,” says Ulloa. “Kids look very, very sick.”

So far, no clear cause has been identified. “The risk factor is being exposed to COVID, period,” says Kleinman. “Not being sicker, not being poorer, not being a particular race or ethnicity. It can happen to anybody.”

The Big Question: Transmission

Scientists have been trying to pinpoint children’s role in the spread of coronavirus since it first emerged.

“Initial data showing kids are less likely to transmit came from circumstances when kids weren’t in school,” says Connor. “I think we need to assume that kids and adults are capable of transmitting the virus to other people.”

Just last week, a new study of nearly 60,000 people in South Korea found that children under 10 years old are the least likely age group to spread the virus—but those aged 10-19 were the most likely.

That makes sense to Ulloa. “We see more severe illness in older children,” she says. “They get more of the classic symptoms that you see in adults.”

Because so many children don’t show any symptoms, the idea that they could be unintentionally spreading the virus looms large. But so far, there hasn’t been enough testing of people without symptoms in this country to determine the risk.

Researchers continue to examine the role children play in transmission. Kleinman is working on a study that compares the spread in households with kids and without. "My impression from preliminary data is that children play a very important role in the transmission of the illness," he says.

This has important implications for families that are attempting to expand their social bubble—to connect with another family taking a similar approach to social distancing, hand washing, and other measures, and socialize only with them.

“You may decide that you're going to share a bubble with a small number of people and I'm not saying you shouldn't do that,” Kleinman says. “But you need to understand that there is risk associated with that. It's only as good as the riskiest behavior inside the bubble.”

Back to School?

Amid all this uncertainty, the new school year is just around the corner. School systems are scrambling to figure out how to bring students back without spurring new outbreaks. Their success will depend largely on how the virus is spreading throughout the community, Connor says. In areas with good control, there are ways to do it safely—and there are huge benefits to in-person school.

On the other hand, “Even if schools are doing their best in terms of health and safety procedures, if there is a lot of COVID transmission in the community, or we don't have a way to identify cases and contact trace and isolate, then what's happening in schools is going to reflect what's happening outside,” she says. “And because schools represent a large group indoor gathering, we can expect to see more spread in schools.”

Kleinman agrees. “I’m truly worried. I think there will be a few schools that can simply do it right. There are many others that will get lucky, and there are some that will not be lucky. People will get sick, die, a few will be children, more will be contacts of children,” he says. And he worries about the potential damage this could do to youngsters’ mental health.

“Even though children aren’t making the decision [about school] so they’re not responsible, some kids’ relatives will get COVID and have serious damage or die. A proportion of these kids will end up with survivor guilt,” he says. “At some point they’ll put it together they’re responsible, rightly or wrongly.”

Show Sources

Lawrence Kleinman, MD, professor, vice chair, department of pediatrics, Rutgers Robert Wood Johnson Medical School.

CDC, “Demographic Trends of COVID-19 cases and deaths in the US reported to CDC,” “Children with Certain Underlying Conditions,” “Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States,” “Multisystem Inflammatory Syndrome (MIS-C)”

Bloomberg News, “Covid-19 Infections on the Rise in Kids and Teens With School Approaching.”

Beth Pathak, Ph.D., co-founder, The COVKID Project.

Journal of Public Health Management & Practice, “COVID-19 in Children in the United States: Intensive Care Admissions, Estimated Total Infected, and Projected Numbers of Severe Pediatric Cases in 2020.”

Nature Medicine, “Age-dependent effects in the transmission and control of COVID-19 epidemics.”

Katherine A. Connor, MD, MSPH, Medical Director, The Rales Health Center at KIPP Baltimore, Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine.

E.R. Chulie Ulloa, MD, MSc, Assistant Professor, UC Irvine School of Medicine, Division of Infectious Diseases, Children's Hospital of Orange County

Emerging Infectious Diseases, “Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020.”

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