COVID-19 in Children: Looking Forward, Not Back - American Academy of Pediatrics
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COVID-19 in Children: Looking
Forward, Not Back
Benjamin Lee, MD, William V. Raszka, Jr, MD
In the fall of 2020, some of the fiercest majority of children with SARS-CoV-2
debates waged in both academic and infection develop mild symptoms3,4 but
public arenas concern the relative question whether children are less
ability of children to acquire and susceptible to infection or less likely to
transmit severe acute respiratory transmit SARS-CoV-2. Limitations of the
syndrome coronavirus 2 (SARS-CoV-2), study include convenience sampling
the causative agent of coronavirus and a relatively small sample size
disease 2019 (COVID-19): rightfully because only 33 households analyzed
so, because there are enormous included children.
implications for children, parents, and
schools. To date, much of the data have Household contact tracing studies
come from studies of COVID-19 within similar to that conducted by Laws et al1
household clusters early during the arguably provide the best evidence
pandemic. In this issue of Pediatrics, regarding pediatric susceptibility to
Department of Pediatrics, The Robert Larner, MD College of
Laws et al1 add to this body of SARS-CoV-2, in which the intensity of Medicine, The University of Vermont, Burlington, Vermont
literature with a secondary analysis of exposure between household contacts
is higher and more consistent than in Opinions expressed in these commentaries are
a previously reported household
those of the authors and not necessarily those of the
contact study.2 They describe infection nonhousehold settings. Although not American Academy of Pediatrics or its Committees.
rates, transmission dynamics, and universal,5 the preponderance of data
DOI: https://doi.org/10.1542/peds.2020-029736
symptom profiles in a cohort of US from numerous countries continues to
support the notion that children are Accepted for publication Oct 1, 2020
children with household SARS-CoV-2
exposure between March and May less susceptible to infection than Address correspondence to William V. Raszka Jr, MD,
Department of Pediatrics, The Robert Larner, MD
2020 in Milwaukee, Wisconsin, and Salt adults.6–13 The results of recent
College of Medicine, The University of Vermont, 89
Lake City, Utah.1 meta-analyses suggest that overall Beaumont Ave, Given Courtyard N210, Burlington, VT
susceptibility in children is 05405. E-mail: william.raszka@med.uvm.edu
The authors found that secondary approximately one-half of that of adults, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
infection rates in household contacts with the greatest effect seen in younger 1098-4275).
were similar in children (19 of 68 children.14,15 In this study, younger Copyright © 2021 by the American Academy of
contacts; 28%) and adults (36 of 120 children had lower rates of infection: Pediatrics
contacts; 30%). Having an infected the odds ratio for infection in 5- to 12- FINANCIAL DISCLOSURE: The authors have indicated
parent was associated with a marked year-olds compared with 13- to 18- they have no financial relationships relevant to this
increase in risk for secondary infection year-olds was 0.36 (95% confidence article to disclose.
in a child. Possible child-to-adult or interval: 0.13–1.05).1 Notably, in FUNDING: No external funding.
child-to-child transmission was virtually all previous studies, POTENTIAL CONFLICT OF INTEREST: The authors have
observed in 2 of 10 and 1 of 6 researchers have relied on reverse indicated they have no potential conflicts of interest
households, respectively, with potential transcription polymerase chain to disclose.
for such events. Infected children reaction to detect infection and, often, COMPANION PAPER: A companion to this article can
generally had mild symptoms and were only test symptomatic contacts. That 4 be found online at www.pediatrics.org/cgi/doi/10.
less likely than adults to report lower pediatric infections in this study 1542/peds.2020-027268.
respiratory tract symptoms or loss of could only be detected by antibody
taste or smell. With their findings, seroconversion suggests that reverse To cite: Lee B and Raszka WV. COVID-19 in
Children: Looking Forward, Not Back. Pediatrics.
the researchers provide additional transcription polymerase chain
2021;147(1):e2020029736
confirmation that the overwhelming reaction–based case detection
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PEDIATRICS Volume 147, number 1, January 2021:e2020029736 COMMENTARY(symptoms-based or otherwise) in a teenager, giving a household among children, is now
children may underestimate the true secondary attack rate of 0.5%.28 incontrovertible.39
infection prevalence.
A significant limitation of household Moving forward, there remains
At the population level as well, cluster data is that most were a critical need for more high-quality
children continue to be generated during school closures, pediatric SARS-CoV-2 research.
underrepresented among SARS-CoV-2 when opportunities for nonhousehold Studies in children are often limited
infections. In numerous large-scale exposure to SARS-CoV-2 among by small sample sizes and binning
studies, researchers have indicated children were scarce. Newer data- into convenient age cohorts that belie
that children, particularly children important differences in biology and
reporting experiences in summer
,10 years old, have much lower rates behavior. The starkest example is to
camps, child care settings, and
of infection than adults do.16–19 In the group all children ,18 years old as
schools (both preclosure and
United States, however, between a single-aged cohort, when there is
postreopening) are helping to fill this
August 27 and September 10, ample evidence that younger children
gap. Importantly, in areas with low
pediatric SARS-CoV-2 infections and older teenagers represent
prevalence rates and appropriate
increased from 9.5% to 10% of all completely different patient
mitigation policies, children
infections, reflecting a months-long populations in the context of SARS-
occasionally become infected, but
summer trend in which regions CoV-2. For example, in the same
there have been no significant
experienced severe outbreaks and region of France, higher rates of
outbreaks. For example, in schools or
physical distancing recommendations potential school-based transmissions
child care programs in Ireland,
were relaxed or ignored as testing were apparent in high schools,
Australia, France, Singapore,
capacity increased.20 Although compared with primary schools.38,40
Germany, and Rhode Island, no to
concerning, children ,18 years A major step forward in pediatric
little facility-based transmission of
old represent 22.3% of the US SARS-CoV-2 research would be the
SARS-CoV-2 by children was
population,21 and this increase has universal establishment of reasonable
reported, despite the presence of
been driven primarily by infections in age strata to enable more
infected children.29–34 However, in
older children. appropriately powered and
areas with widespread community
comparable studies. Elucidating the
The role of children in the transmission or less strict mitigation
mechanisms responsible for
transmission of SARS-CoV-2 is procedures, large outbreaks have
differences in symptomatology,
similarly problematic. In this study, occurred.35–38 Consistently, these
susceptibility, and infectivity between
the researchers found that 20% and outbreaks reveal that infected adults
adults and children will remain
17% of households had potential are typically responsible for
important. However, at this point, we
child-to-adult transmission and child- introducing the virus into these
also need to shift our focus toward
to-child transmission, respectively, settings, questionable testing
the interventions most important for
but numbers are too small to draw strategies enable outbreak initiation,
minimizing the transmission of SARS-
definitive conclusions. Despite some and inconsistent use of masks or
CoV-2 to and from children,
reports of likely onward household cloth facial coverings makes
understanding the pathogenesis of
transmission from infected containment of the virus challenging.
multisystem inflammatory syndrome
children,22,23 in most studies,
in children, and advocating for
researchers suggest that children So, where does this leave us now?
appropriate pediatric clinical trials
appear less likely to transmit, First, children clearly are capable of
for SARS-CoV-2 vaccine candidates.
compared with adults, or present as acquiring and transmitting SARS-CoV-
index cases in household 2. Second, the preponderance of As SARS-CoV-2 continues its
clusters.7,13,19,24–26 In a study from current data still indicates that inexorable march through susceptible
South Korea, researchers generated children have reduced susceptibility populations, we must remember that
considerable alarm when they and infectivity compared with adults, there is no setting on Earth
reported that children 10 to 19 years although this requires further guaranteed to be safe from SARS-CoV-
old appeared as likely as adults to monitoring because increased testing 2. With that sobering recognition, we
transmit infection to household capacity and relaxation of community must work to fulfill the medical,
contacts.27 However, in a subsequent, mitigation may continue to diminish academic, social, and emotional needs
more detailed, analysis of 107 the magnitude of these differences, of children, despite knowing that
pediatric index cases and their which were so stark early during providing such care cannot ever be
household contacts, researchers lockdown periods. Third, the completely free of infectious disease
found definitive evidence of only 1 importance of mitigation measures, risk. As has been shown in the US and
instance of onward transmission from especially the use of masks, including around the world, with appropriate
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2 LEE and RASZKAmitigation strategies, we can before and after symptom onset. JAMA of print October 30, 2020]. J Infect Dis.
successfully minimize (although not Intern Med. 2020;180(9):1156–1163 2020. doi:10.1093/infdis/jiaa691
eliminate) the risk of COVID-19. We 7. Jing QL, Liu MJ, Yuan J, et al. Household 16. Gudbjartsson DF, Helgason A, Jonsson
fear that one day, we will look back secondary attack rate of COVID-19 and H, et al. Spread of SARS-CoV-2 in the
on this terrible pandemic and associated determinants in Guangzhou, Icelandic population. N Engl J Med.
recognize the extent to which we have China: a retrospective cohort study. 2020;382(24):2302–2315
failed our children, by being more Lancet Infect Dis. 2020;20(10): 17. Pollán M, Pérez-Gómez B, Pastor-
afraid of their infection and 1141–1150 Barriuso R, et al.; ENE-COVID Study
transmission risks than of the 8. Li W, Zhang B, Lu J, et al. The Group. Prevalence of SARS-CoV-2 in
prospect of letting them down characteristics of household Spain (ENE-COVID): a nationwide,
precisely when they needed us most. transmission of COVID-19 [published population-based seroepidemiological
online ahead of print April 17, 2020]. study. Lancet. 2020;396(10250):535–544
Clin Infect Dis. doi:10.1093/cid/ciaa450 18. . Korean Society of Infectious Diseases;
ABBREVIATIONS 9. Rosenberg ES, Dufort EM, Blog DS, et al.;
Korean Society of Pediatric Infectious
Diseases; Korean Society of
COVID-19: coronavirus disease New York State Coronavirus 2019
Epidemiology; Korean Society for
2019 Response Team. COVID-19 testing,
Antimicrobial Therapy; Korean Society
SARS-CoV-2: severe acute epidemic features, hospital outcomes,
for Healthcare-associated Infection
respiratory syndrome and household prevalence, New York
Control and Prevention; Korea Centers
state-March 2020 [published online
coronavirus 2 for Disease Control and Prevention.
ahead of print May 8, 2020]. Clin Infect
Report on the epidemiological features
Dis. doi:10.1093/cid/ciaa549
of coronavirus disease 2019 (COVID-19)
10. Somekh E, Gleyzer A, Heller E, et al. The outbreak in the Republic of Korea from
role of children in the dynamics of intra January 19 to March 2, 2020. J Korean
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4 LEE and RASZKACOVID-19 in Children: Looking Forward, Not Back
Benjamin Lee and William V. Raszka Jr
Pediatrics 2021;147;
DOI: 10.1542/peds.2020-029736 originally published online October 8, 2020;
Updated Information & including high resolution figures, can be found at:
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Downloaded from www.aappublications.org/news by guest on January 3, 2021COVID-19 in Children: Looking Forward, Not Back
Benjamin Lee and William V. Raszka Jr
Pediatrics 2021;147;
DOI: 10.1542/peds.2020-029736 originally published online October 8, 2020;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/147/1/e2020029736
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2021
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