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Throughout the pandemic, one of the so-called silver linings that people have clung to is that COVID-19 affects children less than it affects adults. Yet the idea that kids are not impacted by the virus is a myth that is as dangerous as it is inaccurate. We took a deep dive into the myriad ways child health has been impacted – and what we can do about it.
COVID-19 infections and hospitalizations in children
“While children are less likely to become severely ill from the virus that causes COVID-19, kids can get and spread the virus, they can get sick, and some have been hospitalized. Some children have even died, though fortunately deaths have been very rare,” says Children’s Hospital Colorado pediatric infectious disease expert Sean O’Leary, MD, MPH. “We don’t want to add to families’ stress, but we do want parents and children to continue to take COVID-19 seriously enough to maintain precautions — including and especially getting all family members vaccinated as soon as possible.”
Cases in kids – and the proportion of cases – are up
According to a report by the American Academy of Pediatrics, when the pandemic began and many states went into lockdown, children made up 5% of total cases. As of November 11, 2021, more than 6 million U.S. children had tested positive for COVID-19 since the onset of the pandemic. That number represents 17% of all COVID-19 cases.
Here in Colorado, more than 146,000 of the state’s 775,000 cases were in people younger than 19; that’s 19% of the state’s total case count. (Here’s the AAP report from November with full details.)
As restrictions have eased and more people get vaccinated, kids are mingling more. This means that the proportion of total cases made up of kids is getting larger. “It’s simple math,” says Dr. O’Leary, “but it’s a reminder that the virus is still spreading in unvaccinated populations.” With fewer preventive measures in place, we’ll likely see more cases in kids as well. This is why masking and other precautions remain important, especially for kids who aren't yet eligible for the vaccine.
Kids requiring hospitalization and intensive care
While the proportion of kids getting very sick with COVID is low, it isn’t zero. Of the kids who have contracted the virus in the U.S., we know that tens of thousands have been sick enough to need care in the hospital. Experts estimate that out of every 1,000 kids that have a positive COVID-19 test, between 1 and 20 of them will need to be hospitalized.
Think back to life before the pandemic; if up to 20 children in a school of 1,000 students were sick enough to need care in the hospital, it would be remarkable. Here in Colorado, preliminary data show that more than 1,400 kids between 0 and 19 have been hospitalized (equal to 3.2% of the state’s total hospitalizations). Many of them required critical care in the ICU and even mechanical ventilation.
Fortunately, most kids get better with care. But, tragically, more than 625 children in the U.S. have died from COVID-19, including 21 here in Colorado.
“As pediatricians and parents, we want to avoid serious illness, complications and death altogether,” says David Brumbaugh, MD, Children’s Colorado’s Chief Medical Officer. “One death is too many.”
The numbers are more sobering when you consider that childhood deaths in the U.S. – even in a typical year – are rare. During the pandemic, COVID-19 has become one of the top 10 causes of pediatric death.
“This is where the conversation about severity gets a little bit more nuanced,” Dr. O’Leary says. “Yes, it is absolutely true that COVID-19 is less severe in kids than it is in adults, and particularly older adults,” he says, “but in absolute numbers, COVID is causing more harm to kids than influenza, which we consider to be a serious condition for kids, even in a typical year.
“The point I'm making is that yes, it's less severe, but it's still potentially a very severe disease for kids.”
While the rate of children getting seriously ill from COVID-19 is lower compared to the rate of adults, COVID-19 can be serious, even for healthy kids. Fortunately, we now have a safe and effective vaccine for most children and teens (5 and older) that helps protect them from the risks of COVID.
A note on delta, other variants and how they could affect kids
When examining how COVID impacts kids, there’s an important caveat: Variants of the virus – like delta and omicron – could change the severity of the disease.
Viruses mutate naturally, and scientists expect new variants of viruses as they spread. There have been multiple mutations of the SARS-CoV-2 virus since it first emerged, though most have not affected the function of the virus until recently. What’s different now is that some versions of the new coronavirus have mutated enough that they have changed how the virus works: mostly how easily it’s able to spread.
“The delta variant quickly emerged as the dominant variant across the globe,” says Samuel Dominguez, MD, PhD, a pediatric infectious disease specialist and expert on coronaviruses. “With delta, the virus changed enough that it is more easily transmitted from one person to another. We’re still learning whether the delta variant is also more likely to cause more severe illness in people, including children. But considering how easily it spreads, we’ve seen cases in kids and hospitalizations in kids increase too, simply because more people are getting sick.”
It’s still too early to know how disease severity may change with the latest variant of concern – omicron. We do know that omicron is even more transmissible than delta, and that's how it quickly became the dominant strain in Colorado. “This is why it’s more important than ever to get vaccinated if you’re eligible and to continue wearing masks in indoor public spaces,” Dr. Dominguez says.
Delta and omicron emerged because of uncontrolled spread, and more dangerous variants could also emerge if uncontrolled spread continues. The bottom line? Viruses can’t mutate if they can’t replicate. Stopping transmission using the tools we have – vaccines, masks, ventilation, distancing and hand-washing – is critical for stopping variants, too. And it takes all of us, even those who aren’t at great risk of severe disease, to contain the spread.
COVID-19 complications in kids
Not only can kids get sick with and spread COVID-19, some of the kids who get infected are experiencing complications beyond the initial infection.
Long COVID in kids
Anyone who has had a bad virus or mononucleosis, often shortened to “mono,” knows that some symptoms of viral infections can hang around for a while. Another COVID-19 complication is referred to as “long COVID,” or post-acute COVID-19 syndrome, abbreviated as PACS. This is when symptoms continue, or new symptoms begin, in the weeks or months after someone has had the coronavirus.
Though much of the media coverage has focused on this phenomenon in adults, it’s affecting kids, too. According to a 2021 study that analyzed the medical records of nearly 2 million people, nearly a quarter of those who contracted the coronavirus have reported long-term symptoms or new health problems since they had the virus. That number includes children. Another recent study in the U.K. found that most children recover from COVID within six days, on average, but that 4.4% of them experience symptoms for four weeks, and 1.8% for eight weeks or longer. Experts are still learning about what’s causing PACS in some people, and who is more likely to experience long-term symptoms. We'll learn more as studies continue.
The list of symptoms associated with this evolving condition is long; however, common symptoms include increased tiredness (fatigue), difficulty thinking or concentrating (sometimes referred to as “brain fog”), ongoing cough, painful joints and muscles, dizziness on standing, headache and more. Some symptoms may come and go, while others may appear many weeks or months after the initial infection.
If parents have concerns about long COVID, Dr. Brumbaugh recommends they reach out to their children’s pediatrician. “Pediatricians are well equipped to help kids who have enduring symptoms of COVID-19. If you’re concerned your child’s health hasn’t returned to normal, their primary care team can make practical recommendations to get them back on track, like sleep, nutrition and exercise to help address fatigue, or can help ease any lingering symptoms.”
With some vague symptoms, like fatigue, it can be difficult to tease out whether the symptom is related to a post-viral syndrome, a new illness or even sleep disruption from changing routines. What matters is this: Pediatricians can help manage these symptoms, and we expect these kids will get better.
Loss of taste and smell
It’s well established that the new coronavirus can impair one’s sense of smell during sniffing or eating, resulting in the loss of taste and smell. The medical term for this is “olfaction dysfunction.” Some people’s senses may be off for weeks or months following COVID infection.
Because young kids may not easily articulate that their senses of smell and taste aren’t normal, our experts believe that the loss of smell and taste in kids may be vastly underreported.
“If a significant percentage of children have COVID-19 but don’t have symptoms and your child says, ‘Mom and dad, this milk doesn’t taste right,’ it’s easy to write this off as something like picky eating that day or even spoiled milk,” pediatric ear, nose and throat doctor Kenny Chan, MD, explains. He’s started an olfactory training clinic and research study to investigate whether children who have lost their taste and smell can retrain these senses.
A story in the Colorado Sun explains how olfactory training works, and what our experts are looking for.
Published studies so far estimate 5% to 9% of children who contracted COVID experience olfactory disruption. “We want to understand the olfactory effect of COVID in children,” Dr. Chan says. “It will be an important part of shedding light on this virus impacting the world.”
One of the most troubling threats to kids from COVID-19 is the rare condition called multisystem inflammatory syndrome in children, or MIS-C. MIS-C can cause dangerous inflammation in multiple organs, including the heart and gastrointestinal tract, even in children who had mild or asymptomatic cases of COVID-19. Kids who develop MIS-C need care in the hospital, many in intensive care.
Nationwide as of November 30, more than 5,500 children have had MIS-C and more than 50 have died, according to the Centers for Disease Control and Prevention. In Colorado, almost 150 children have been diagnosed with MIS-C. It takes additional time for the CDC to investigate and confirm these cases, which means these numbers are likely an undercount.
“Thankfully, most of the children we have treated with MIS-C have done well with aggressive therapy,” says Dr. Dominguez. “The worrisome thing is that we don’t know if it will have long-term impact, especially on the heart — that’s why we’re participating in a study that explores potential long-term effects.”
Though we encourage parents to be aware of the symptoms of MIS-C, fortunately, it remains rare.
So, are children at lower risk of COVID-19 than adults? As a group, yes. Is COVID-19 less severe in kids? Overall, yes. But – like so many things – it’s nuanced and it will take time to create a more complete picture. And then there are the indirect effects of living through a pandemic.
The pandemic’s indirect effects on children
Family loss and COVID-19-associated orphanhood
The ripple effects of COVID-19 include hundreds of thousands of children who have lost a family member to the virus here in the U.S. and millions worldwide. Studies in The Journal of Pediatrics and The Lancet show:
Children of color especially affected
Here in the U.S., children of racial and ethnic minorities were much more likely to have lost a caregiver. The study published in Pediatrics shows the disparities starkly: Though people of color make up about 40% of the U.S. population, children of color represented 65% of the children who lost a caregiver. While about 60% of the country’s population is white, about 35% of the children who have lost a caregiver are white.
Put another way, the risk of such loss was 1.1 to 4.5 times higher among children of racial and ethnic minority groups compared with non-Hispanic white children. Here’s how it breaks down by group:
- 1 in 168 American Indian and Native Alaskan children have experienced the death of a parent or caregiver from COVID-19.
- 1 in 310 Black children have experienced the death of a parent or caregiver from COVID-19.
- 1 out of 412 Hispanic or Latino children have experienced the death of a parent or caregiver from COVID-19.
- 1 out of 753 white children have experienced the death of a parent or caregiver from COVID-19.
Bereavement’s long-term effects
“We are only beginning to see the impact of this widespread bereavement,” says Jenna Glover, PhD, a child psychologist. “Losing a parent during childhood is extremely traumatic and has been linked to higher risk of mental health problems, substance abuse, lower academic performance and even early death.”
Experts are seeing grieving kids who are dealing with new home environments and routines.
“Grief often manifests as difficulties. New caregivers then come in and say, ‘This child is really struggling with sleep. They're refusing to eat. They don't want to go to school. They don't want to sleep without me.’ Those are some of the common things that we’re seeing,” Ayelet Talmi, PhD, another pediatric psychologist explained to KUNC radio.
The fact that these children lost their parents at a time when mental health services, and even basic services such as in-person school and sports, were extremely hard to come by compounds the long-lasting effects, Dr. Glover says.
Impact on children’s mental health
Amid the fear and uncertainty of the past year and without the support and social interaction that in-person school normally provides, children are suffering from more stress, anxiety and depression. Children’s Colorado declared a state of emergency for youth mental health after emergency department visits due to anxiety and depression or feelings of isolation and hopelessness, rose 72% in the first five months of 2021 compared to the same time period in 2019. In October, the Children's Hospital Association, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry declared the state of American kids’ health a national emergency.
"I've been in practice for over 20 years in pediatrics and I’ve never seen anything like the demand for mental health services we’ve seen in the past 15 months," says Dr. Brumbaugh. "There have been many weeks in 2021 that the number one reason for presenting to our emergency department is a suicide attempt. Our kids have run out of resilience – their tanks are empty."
Suicidal ideation among adolescents
According to a report from the CDC, after an initial drop due to lockdowns, emergency department visits for suspected suicide attempts began to increase among 12- to 17-year-olds, especially girls. Between February and March 2021, ED visits due to suspected suicide attempts increased 50.6% among girls ages 12 to 17 years over the same period in 2019. Among boys of the same ages, suspected suicide attempt emergency department visits increased 3.7%.
“We were already in a fire,” Dr. Glover says about the state of youth mental health. “The pandemic is fuel on that fire.”
Responses to over a year of change
Adding to this challenge is the learning loss that kids face after a year of mostly online school. “This crisis has grown as kids return to school and are trying to adjust to making up for a year of lost development,” Dr. Glover says. “Kids are being asked to get back into life again, and they don't have the resources to do that. They're burnt out, and they feel so behind they don't know how to catch up."
On top of it all are the financial stressors that many families are facing due to the pandemic, which only add to children’s stress. “Our kids are co-regulators; they manage their emotions how we manage our emotions. When our levels of stress are much higher their levels of stress are going to be much higher. Think about all of the uncertainty and change we’ve experienced. Kids have had family members lose jobs, lose friends and family members – it all compounds.”
The mental health fallout from the pandemic is expected to last a long time.
“Death loss, loss of income, loss of lifestyle and quality, loss of relationships and connections – these all have implications on child and family wellbeing,” says Dr. Talmi. “We need to brace ourselves to be in it for the long haul,” she adds.
Find tips on monitoring and bolstering your children’s mental health during the pandemic.
Protecting kids from the harmful impacts of COVID-19
Due to the detrimental impacts the pandemic has had on children, it’s imperative to protect them. And here’s the good news: We know how to protect kids from COVID-19.
First and foremost, it’s vaccines. A safe and effective vaccine for kids 5 and older – the Pfizer COVID-19 vaccine – is readily available in the U.S.
“We need a vaccine for children not just to achieve herd immunity, but also to protect the children themselves,” says Dr. O’Leary. “Vaccination protect kids not just from getting COVID, but from getting a severe case of COVID requiring time in the hospital, MIS-C, and a host of potential long-term complications of the virus, too.”
Another key benefit of getting kids vaccinated as soon as they’re eligible is to enable them to skip quarantines that keep them out of school and negatively impact their mental health. Additional prevention tools such as masks indoors and frequent hand-washing help keep kids safe while regaining some normalcy, like safe in-person learning and activities.
As tempting as it may be to forego COVID precautions because some claim, “it just isn’t as serious in kids,” maintaining safeguards like masking and getting kids vaccinated as soon as they’re eligible is the safest road back to normalcy.
“We know this has already been a long road for parents, and we understand that keeping up with recommended precautions can be stressful,” says Dr. Dominguez. “Our goal is to support parents in easily getting the information they need to protect their kids effectively so that Colorado children can remain as safe and healthy as possible while returning to the activities that they love. We can do this.”
Learn about the COVID-19 vaccines, and spread the word. Or find out how to get vaccinated at Children’s Colorado.