June 7, 2021 -- Kate Oakes, a Chicago mother, says she finds this point in the pandemic especially confusing. She and her husband are vaccinated against COVID-19, but the vaccines aren’t yet available for children under the age of 12, so their 7-year-old daughter hasn’t gotten one yet. Oakes says that makes figuring out what they can safely do now as a family very challenging.

“Now that my husband and I are vaccinated, we feel all sorts of new freedoms to do things like dine indoors at a friend's house or at a restaurant, maybe even go see some live music or to a movie,” Oakes says. “But what are the risks associated with these activities as far as what we could potentially expose our daughter to?”

Oakes says she and her husband find they’re now faced with a seemingly never-ending list of questions about what they can safely do with whom and who needs to wear masks in a variety of settings. Can her daughter go to the sleepover she was invited to? Does she need to wear a mask? What if the other kids aren’t wearing them -- does she stay? Can unvaccinated kids ride in the car with them? Can her family get on a plane yet? If a loved one flies into town does being on a plane make them higher risk around her unvaccinated daughter?

“Overall trying to figure this all out is so nerve-racking,” Oakes says.

Linda Friehling, MD, an assistant professor in the division of pediatric general medicine at the University of West Virginia, says she has great sympathy for parents and caregivers trying to navigate this moment in the pandemic. “There’s a lot of confusion because this pandemic is still evolving and our knowledge and understanding of it is constantly changing, too,” Friehling says. “We in the medical profession don’t have all the answers yet. That is the honest truth. We’re trying to figure out what’s best for everyone too.”

Kids and COVID: What We Know

Let’s start with the good news. The CDC says COVID cases are down 94% since June 2020, and as of May 27, 2021, the American Academy of Pediatrics (AAP) data showed the lowest number of weekly cases of COVID in children (34,500) since October.

The AAP says nearly 4 million children have tested positive for the virus since the beginning of the pandemic, but hospitalization rates of kids are low. Children make up 1.3%-3.2% of total reported hospitalizations and just 0.1%-1.9% of children with COVID-19 are hospitalized. COVID deaths among children are low too -- making up 0.23% of all COVID-19 deaths.

“We do seem to be at the point where cases are decreasing. That is certainly the hope,” Friehling says. “What we don’t know is whether seasons and variants will change that.”

The CDC says fewer children have been sick with COVID-19 compared with adults and most have mild symptoms, although children can get severely ill from the virus and require hospitalization.

There is increased protection to unvaccinated children and adolescents as adults get vaccinated And now, more than 6.7 million children age 12-17 have received at least one vaccine dose. But new data is also raising concern about hospitalization rates in teens, compelling CDC Director Rochelle Walensky, MD, to urge parents to get all teens and adolescents vaccinated if they are eligible.

Walenksy said new CDC data released Friday shows after initially declining in early 2021, teen hospitalization rates from COVID rose in March and April. The CDC looked at more than 200 adolescent hospitalizations and found that none died, but nearly one-third were admitted to intensive care (ICU) and 5% needed “invasive mechanical ventilation.”

“CDC observed troubling data regarding the hospitalizations of adolescents with COVID-19. More concerning were the number of adolescents admitted to the hospital who required treatment in the intensive care unit with mechanical ventilation,” Walensky said at a White House briefing last week. “It is these findings … that demonstrate the level of severe disease, even among youth, that are preventable, that force us to redouble our motivation to get our adolescents and young adults vaccinated.”

“I strongly encourage parents to get their teens vaccinated, as I did mine,” Walensky added.

Vaccines are proving very effective against COVID so far in teens. Pfizer says two doses demonstrated 100% efficacy among teens and young adults as of May 27. The CDC says more than 165 million people have received at least one dose of the vaccine and serious side effects are rare. Another reason to vaccinate adolescents is that vaccines aren’t foolproof. Breakthrough infections are rare but do happen. Of more than 130 million people fully vaccinated as of May 24, 2,454 people were later hospitalized or died from vaccine breakthrough cases, according to the CDC.

The agency is investigating a very small number of reports of heart inflammation in teen and young adult vaccine recipients, calling them “rare.” The American Academy of Pediatrics says most cases have been among male teens and young adults over the age of 16 and most have responded well to rest and medicine and “quickly felt better.”

So which children are most at risk to COVID-19 in general? The CDC says babies under the age of 1 and children with underlying health conditions may be more likely to have severe illness if they get the virus. Conditions that put children at increased COVID risk include:

  • Asthma and chronic lung disease
  • Obesity
  • Diabetes
  • Immunosupression -- from medical conditions or medications
  • Genetic, neurologic, or metabolic conditions
  • Sickle cell disease
  • Heart disease since birth
  • Medical complexity -- multiple chronic conditions or reliance on technology or other supports for daily life

“Just like influenza, little babies have an increased risk to viruses like this,” Friehling says. “Obesity and severe asthma are risk factors for COVID and we want to be especially careful for immunosuppressed children, those with cancer, transplants, autoimmune issues, and any child on chronic steroids. They may struggle to make antibodies when they do get the vaccine, too, so they’re going to have to rely on herd immunity to best protect them.”

There’s also the issue of a rare but serious condition associated with COVID-19 in children called Multisystem Inflammatory Syndrome in Children (MIS-C). The CDC says it continues investigating MIS-C, which causes inflammation in multiple organs making children very sick and generally requiring them to be hospitalized.

The CDC says the cause isn’t yet known, but many children with MIS-C did have the virus that causes COVID-19 or they were around someone who had it. MIS-C can be deadly, but most children recover once they’re treated for it.

“MIS-C hasn’t been ironclad connected to COVID though it seems there is a propensity for it,” Friehling says. “We have had seven children hospitalized with it in our hospital. The good news is -- all of them were treated, recovered, and released.”

Navigating the Pandemic in Real Life

Knowing the latest data is one thing. Figuring out how to apply it in real life with your own children is quite another. Brenda Zuniga admits she’s also struggling to understand what’s best for kids at this point in the pandemic. The 23-year-old is the main English speaker in her family so she helps her parents, whose native language is Spanish, make decisions for her younger siblings.

“I have to think like head of household and field this data myself and make sure my parents and whole family understand what we’re doing and why,” Zuniga says. “I have to translate and interpret all of this for them so I’m trying my best to do as much research as I can, but it’s hard to keep up with it all. It seems like things keep changing.”

Here’s the latest guidance from the CDC.

If children and teens are fully vaccinated:

  • They don’t need masks inside or out and no longer need to physically distance from others unless asked to in places like hospitals, health care settings, and on public transportation.
  • If they have a weakened immune system, they may still need to wear masks after vaccination because their body may not develop antibodies to fully protect them. Talk with their doctor about the best way to proceed.

If children are not vaccinated:

  • They do not need to wear masks outside for activities with members of their own household like taking a walk or bike ride, at small gatherings with fully vaccinated family and friends, during water sports like swimming or if they’re under the age of 2.
  • They are encouraged to wear masks outside at small gatherings with vaccinated and unvaccinated people or if dining outdoors with multiple households.
  • They are encouraged to wear masks indoors, even inside their home or someone else’s if they’re around people from other households.
  • Good hand-washing and social distancing are still recommended.
  • Virtual playdates are considered lowest risk. Infrequent playdates with the same family or friend following CDC guidelines are moderately risky so 6-feet physical distancing is recommended and playdates should be held outdoors if possible. Frequent indoor playdates with multiple friends and family and no social distancing are considered highest risk.
  • Travel increases a child’s chances of coming into contact with COVID-19 and spreading it.

“The simplest tip is to always carry masks for the entire family in case you or your children need to go indoors or be in close contact with people who may not be vaccinated; so easy, and yet effective,” says Michael Smit, MD, medical director of infection prevention and control at Children’s Hospital Los Angeles.

Friehling agrees and says she’s having conversations with many of her patients and their families about when it’s safe for them to take the mask off. “When a young unvaccinated child is wearing a mask and running around and playing outside in the heat, I think it could be a detriment rather than a help, so I’ve been telling families if you’re outside with those who are vaccinated this summer or you can physically distance, don’t mask your children,” Friehling says. “But outside can mean a lot of different things -- from playing with the neighbors to going to a baseball game. So if you’re around a lot of people outside, then do put the mask on children and keep them masked inside too.”

“I'm OK with them not wearing masks at this stage of the pandemic outside if it’s not busy,” agrees Mark Pasternack, MD, chief of pediatric infectious diseases at MassGeneral Hospital for Children in Boston. “But the risk of indoor exposure is still an issue for me personally. As a parent and grandparent, I'm very conservative when it comes to the health of younger folks so if they’re inside somewhere other than your home, I’d have them wear a mask.”

As for swimming, sleepovers, birthday parties and more, Friehling admits decisions will likely vary case by case. She urges adults to ask others about their vaccination status to make the most informed decisions possible for their children. “Parents are within their rights to find out if people are vaccinated. If you have a young child who can’t be vaccinated or one with medical issues, I think you can ask to help make your decisions,” Friehling suggests.

Beyond that, Friehling says her best general advice for parents is talk with their pediatrician to understand what is best. She says guidance is going to be somewhat variable, based on whether their child or a family member is high risk for COVID, along with rates of transmissions and vaccinations in your community.

As for the vaccine, every doctor WebMD spoke with recommends it for children once it’s approved and available for their age. “If and when it’s possible for your children -- vaccinate. I recommend it for those 12 and above now and once it’s been tested and becomes available for ages 5-12, I’ll expect I’ll be in favor of it for younger children, too,” Friehling says. “Testing has been strong and careful. We have a robust surveillance system in place to look for rare side effects. This vaccine is safe. We give young children several vaccines and I believe this one should be included in that list once the FDA finds it safe to do so.”

Pasternak agrees. “Once it is approved for various age groups, I support it -- in general and for my own family as well,” he says. “If everyone will get immunized, we really will all be better off and I want that for all of us -- and especially for kids. My hope is they will get back to some sense of normal because it’s been shown from an educational, social, emotional, and psychological perspective, this pandemic has had staggering effects on kids.”

Oakes says she’s looking forward to the day her daughter can get vaccinated, too. Until then, she and her husband are being very thoughtful about what they do and don’t do. “Overall I'm still being cautious to not do things I wouldn't have my daughter do -- whether or not she is with us,” Oakes explains. “It's such a relief to be unmasked in certain situations, but it still feels weird. I just can't wait for my daughter to be vaccinated, too!”

Show Sources

Kate Oakes, Chicago.

Linda Friehling, MD, West Virginia University, Morgantown, WV.

Shipra Gupta, MD, Pediatric Infectious Disease, West Virginia University.

Mark Pasternack, MD, MassGeneral Hospital for Children, Boston.

Michael Smit, MD, Children’s Hospital Los Angeles.

Brenda Zuniga, Woodbridge, VA.

American Academy of Pediatrics: “Critical Updates on COVID-19,” COVID-19: State-Level Data Report.”

AAP News: “CDC releases guidance for clinicians on heart inflammation after COVID_19 vaccination,” May 27, 2021.

Pfizer: “Pfizer-Biontech Announce Positive Topline Results of Pivotal COVID-19 Vaccine Study in Adolescents,” March 31, 2021.

CDC: “COVID-19 in Children and Teens  -, Myocarditis and Pericarditis, MIS-C Info for Parents,” “Weekly Review, May 28, 2021,” “Stop the Spread in Children,” “When You’ve Been Fully Vaccinated,” “COVID-19 Breakthrough Case Investigations and Reporting,” “Guidance for Wearing Masks,” “Choosing Safer Activities.”

Rochelle Walensky, MD, director, CDC.

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