Quotes from Experts

COVID-19 cases in children

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May 21, 2020


Are children less likely than adults to acquire or spread COVID-19?


“Up to this time, there are no rigorous studies conclusively demonstrating whether children are more or less likely to acquire or transmit SARS-CoV-2 virus when compared to adults.

”What is known from several large national registries in the United States and Europe is that children are far less likely to test positive for SARS-CoV-2 compared to adults, even after accounting for the smaller proportional representation of children in the entire population. What has yet to be established is whether children make up a very small proportion of confirmed COVID-19 cases because they have less exposure to the virus, or have better immunologic resistance to the virus, or are more often asymptomatic and therefore are less likely to be tested, compared to adults.” (Posted May 21, 2020)

Jeffrey P. Burns, MD, MPH
Chief of Critical Care--Boston Children’s Hospital, Professor of Anaesthesia—Harvard Medical School

“We do not really know whether children are more or less likely to acquire COVID-19. Here, we have to be careful to distinguish between symptomatic and asymptomatic disease. If we don’t test everyone, then we won’t detect much asymptomatic disease, and so could not make an accurate, quantitative statement about the likelihood of a child being infected, since by “infected” we would include both asymptomatic and symptomatic children. Children generally seem to be less severely affected than adults, although there are certainly some cases reported of severely affected children. Infants (less than a year of age) and adolescents appear to have more severe disease than children older than infants and younger than adolescents. Children of those ages, in addition to experiencing less severe disease, also seem more likely to have asymptomatic disease. Because children appear to be more likely to have asymptomatic disease, they may be more likely to spread the disease, because others may be less likely to maintain strict social distancing with asymptomatic children. There are also likely to be other social and behavioral factors involved. When children—particularly young children—play together, they tend to play in close contact with each other, enhancing the risks of spreading the disease. Adults also instinctively tend to hug young children, and those kinds of behaviors may also enhance disease spread.

“Despite being, in general, less severely affected, some children experience severe disease. It should not just be assumed that children with COVID-19 will automatically do well. If a child with COVID-19 (or without, for that matter) appears to be ill, they should be brought to medical attention quickly.” (Posted May 21, 2020)

Steven L. Zeichner, MD, PhD
Professor, Departments of Pediatrics & Microbiology, Immunology, and Cancer Biology; Director, Pendleton Pediatric Infectious Disease Laboratory; Head, Division of Pediatric Infectious Diseases, The University of Virginia

“No but they are more likely to experience asymptomatic or mildly symptomatic illness.” (Posted May 21, 2020)

Anne H Rowley, MD
Professor of Pediatrics and of Microbiology/Immunology, Northwestern University Feinberg School of Medicine and The Stanley Manne Research Institute, Attending Physician, The Division of Infectious Diseases The Ann & Robert H Lurie Children’s Hospital of Chicago

Does COVID-19 manifest differently among young people? How so?


“Similar to the experience with adults, a recent study of COVID-19 leading to critical illness in children in North America found that 80% had one or more co-morbidities and that three-quarters presented with respiratory symptoms, but generally with less severe manifestation of illness. Why children have less severe manifestation of illness from COVID-19 than adults has yet to be determined. Again, it could be because they have less exposure to the virus, or have better immunologic resistance to the virus.” (Posted May 21, 2020)

Jeffrey P. Burns, MD, MPH
Chief of Critical Care--Boston Children’s Hospital, Professor of Anaesthesia—Harvard Medical School

“Children generally tend to have milder or asymptomatic disease, although there are exceptions. Babies and older children/adolescents may be more severely affected than other children.” (Posted May 21, 2020)

Steven L. Zeichner, MD, PhD
Professor, Departments of Pediatrics & Microbiology, Immunology, and Cancer Biology; Director, Pendleton Pediatric Infectious Disease Laboratory; Head, Division of Pediatric Infectious Diseases, The University of Virginia

“In general, mild or no illness.” (Posted May 21, 2020)

Anne H Rowley, MD
Professor of Pediatrics and of Microbiology/Immunology, Northwestern University Feinberg School of Medicine and The Stanley Manne Research Institute, Attending Physician, The Division of Infectious Diseases The Ann & Robert H Lurie Children’s Hospital of Chicago

What factors increase the likelihood that children will experience severe COVID-19 symptoms?


“Most people believe that it is likely that children with severe underlying diseases, for example heart, lung, and kidney diseases, children with immune system disorders, other chronic diseases, and children being treated with therapies that affect the immune system, will be more severely affected than otherwise healthy children, as has been seen in adults.” (Posted May 21, 2020)

Steven L. Zeichner, MD, PhD
Professor, Departments of Pediatrics & Microbiology, Immunology, and Cancer Biology; Director, Pendleton Pediatric Infectious Disease Laboratory; Head, Division of Pediatric Infectious Diseases, The University of Virginia

“Teenagers with COVID-19 may have some of the same risk factors as adults, such as obesity, hypertension, and type II diabetes.” (Posted May 21, 2020)

Anne H Rowley, MD
Professor of Pediatrics and of Microbiology/Immunology, Northwestern University Feinberg School of Medicine and The Stanley Manne Research Institute, Attending Physician, The Division of Infectious Diseases The Ann & Robert H Lurie Children’s Hospital of Chicago

What is multisystem inflammatory syndrome in children (MIS-C) and how is it related to COVID-19?


“In mid to late April in Western Europe, and then several weeks later on the East Coast of the United States, physicians noted a marked increase in children hospitalized with an acute illness of persistent fever and a mix of signs and symptoms such as rash, abdominal complaints and low blood pressure leading to multiorgan failure and shock. Some of the most ill patients have a presentation consistent, partially or completely, with Kawasaki disease, a disorder leading to inflammation of the blood vessels, most worrisomely the coronary arteries of the heart, for which there are proven treatments such as intravenous immunoglobulin.

“This multisystem inflammatory syndrome appears to follow with the peak prevalence of COVID-19 in the general population by about 4 weeks, suggesting a temporal association with the SARS-CoV-2 virus. In addition, many of these children have IgG antibodies against SARS-CoV-2 without evidence of viral shedding. These findings have led to a concern, yet to be verified, that the multisystem inflammatory syndrome might represent post-infectious inflammatory response where the inflammation is not caused by a primary infection by SARS-CoV-2, but rather by the patient’s own immune system. In this scenario, the child successfully mounted an immune response to the SARS-CoV-2 virus 4 weeks or so earlier, and had few if any symptoms of infection at that time, but now many weeks later is experiencing fever and inflammation because that same immune response is now in an accelerated state. Fortunately, to date, most of these cases are rare and self-limited, but a few children have become critically ill from this syndrome, and fewer still have died, in both Europe and the United States.” (Posted May 21, 2020)

Jeffrey P. Burns, MD, MPH
Chief of Critical Care--Boston Children’s Hospital, Professor of Anaesthesia—Harvard Medical School

“Multisystem inflammatory syndrome in children (MISC) is a relatively newly described syndrome that seems to be associated with COVID-19, although a definitive causal relationship has yet to be established. MISC was first described in Europe, and then there were a number of cases on the US East Coast, and now a few in the Midwest and South. Interestingly, MISC was not observed in China and other countries of East Asia, where the virus first jumped into the human population, and was not observed, at least initially, on the US West Coast, where the first US COVID-19 outbreaks were reported. The reasons for these geographic differences are not known, but some investigators have hypothesized that there may be either genetic differences in the children that predispose them to MISC or that the virus has somehow mutated during its movement through Europe to the US East coast in such a way as to increase the likelihood of MISC. While serious, MISC is still a relatively rare complication of COVID-19 (assuming that it is, in fact, caused by COVID-19).

“Children with MISC have fever, clinical signs and laboratory test evidence of inflammation, and evidence that one or more of their organ systems (skin, heart, lungs, kidneys, gastrointestinal system, brain and neurological system) are severely affected. MISC may be confused with other serious systemic disorders, including other serious viral and bacterial infections.

“Children with MISC can be very severely affected. They can become severely ill very quickly. They should be cared for in tertiary care centers with access to a pediatric intensive care unit and comprehensive set of pediatric subspecialists. Since we are still learning about MISC, these children should be enrolled clinical trials and observational studies so that we can learn more about the disease and take better care of that particular patient and other patients.

“MISC has sometimes been compared to Kawasaki disease, with which it shares some, but not all features.

“Treatment for COVID-19 and for MISC is primarily supportive. There are no FDA-approved therapies for either disorder. There are clinical trials involving antivirals for COVID-19, and some antivirals and other agents are being used on a compassionate use basis. Some FDA-approved drugs are being used off-label. In general, all these therapeutic interventions should be done in the context of a clinical trial, as recommended by the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society, NIH, CDC, and other national drug approval agencies. This includes chloroquine/hydroxychloroquine with or without azithromycin, lopinavir/ritonavir (Kaletra), convalescent plasma, and immunomodulators, such as IL-6 blockers, such as tocilizumab. In early trials, the antiviral remdesivir, for which the FDA has provided an Emergency Use Authorization for COVID-19 for use with hospitalized patients with severe disease, appears to modestly shorten the duration of hospitalization, but without, as yet, a demonstrated effect on mortality. Remdesivir is available for children and pregnant patients through an emergency access program.

“Children with MISC can become ill very quickly, and so should be treated in a hospital with pediatric intensive care capabilities and access to a broad range of pediatric subspecialty support, since many different systems can become involved in the disease process. There is no specific therapy for MISC. Because the syndrome, in some ways, resembles Kawasaki disease, some pediatricians are using treatment strategies similar to those used for Kawasaki disease, such as intravenous immunoglobulin. Disease registries and clinical trials are under development, and children with MISC should be enrolled in these as they become available. MISC is very recently described and new information is becoming available on a daily basis, so these statements will likely change soon.” (Posted May 21, 2020)

  • The Pediatric Infectious Disease Society has issued a press statement concerning MISC. It can be found here.

  • An alert from the CDC on MISC can be found here.

  • The UK Royal College of Paediatrics and Child Health guidance document can be found here.*

Steven L. Zeichner, MD, PhD
Professor, Departments of Pediatrics & Microbiology, Immunology, and Cancer Biology; Director, Pendleton Pediatric Infectious Disease Laboratory; Head, Division of Pediatric Infectious Diseases, The University of Virginia

“While these two conditions can share a few features like fever, rash, and red eyes, there are many differences between them, including demographic features (age/race), clinical symptoms, nature of cardiac findings, and laboratory findings. The majority of patients with the new syndrome have evidence of active or—more often—recent infection with SARS-CoV-2. The new syndrome behaves like a complication after infection with SARS-CoV-2, manifesting some weeks after the active infection, and children usually are asymptomatic during their active infection period.” (Posted May 21, 2020)

Dr. Stanford T. Shulman, MD
Professor of Pediatric Infectious Disease, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School, Chicago

“This is a term originally used to describe a very small number of children, primarily over age 6-8 years, who develop severe abdominal pain, fever, and inflammation of the heart muscle with markedly elevated cardiac damage molecules in the blood. Recently the term has been broadened to include a range of other inflammatory conditions, and it is not clear whether this broader definition is picking up this new disorder primarily. Many children with other different inflammatory disorders unrelated to COVID-19 could be reported based on broad case definitions.” (Posted May 21, 2020)

Anne H Rowley MD
Professor of Pediatrics and of Microbiology/Immunology, Northwestern University Feinberg School of Medicine and The Stanley Manne Research Institute, Attending Physician, The Division of Infectious Diseases The Ann & Robert H Lurie Children’s Hospital of Chicago

* Links included in quotes were supplied by the expert.


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Jeffrey P. Burns, MD MPH, Chief of Critical Care–Boston Children’s Hospital, Professor of Anaesthesia—Harvard Medical School

No conflicts.

Steven L. Zeichner, MD, PhD; Professor, Departments of Pediatrics & Microbiology, Immunology, and Cancer Biology; Director, Pendleton Pediatric Infectious Disease Laboratory; Head, Division of Pediatric Infectious Diseases, The University of Virginia

Dr. Zeichner is an inventor on patent applications that describe potential new vaccines for COVID-19 and other diseases. The University of Virginia owns the patent applications. Under the terms of the University of Virginia intellectual property policies, Dr. Zeichner could benefit financially and personally and obtain additional support for his research if the intellectual property ever earns money, which has not yet happened.

Dr. Stanford T. Shulman, MD, Professor of Pediatric Infectious Disease, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School, Chicago

No disclosures.

Anne H Rowley MD, Professor of Pediatrics and of Microbiology/Immunology, Northwestern University Feinberg School of Medicine and The Stanley Manne Research Institute, Attending Physician, The Division of Infectious Diseases The Ann & Robert H Lurie Children’s Hospital of Chicago

No conflicts related to this topic. Receiving grant funding from National Institutes of Health and The Falk Medical Research Trust. A provisional patent application filed by Northwestern/Lurie regarding a protein targeted by the antibody response to Kawasaki disease.