Addressing Common Questions about Children Returning to School

young girl in classroom wearing a mask

Children’s Hospital at Dartmouth-Hitchcock (CHaD) Pediatricians Susanne Tanski, MD, MPH, and Samantha House, DO, MPH, summarize the current literature to answer some of the common questions people have about their children returning to school:

How many kids are getting infected with SARS-CoV-2?

In the U.S., as of August 20th, children represented 9.3% of all positive cases in the country (with more than 70 million tests completed for all ages)—children under age 18 make up 22% of the U.S. population. Testing of children has changed over time, with only symptomatic patients tested initially, followed by more community testing of less symptomatic patients over time. Recent testing of 33,000 asymptomatic children at 28 children’s hospitals for ear, nose and throat procedures showed only 0.65% of them to be positive for SARS-CoV-2.

As of August 24th, in New Hampshire, only 160 out 7,107 COVID+ cases (2.3%) have been nine years of age and younger, with an additional 365 in the 10-19 age group (5.1%). This is a total of 525 (7.4%). In Vermont, only 55 out of 1,557 COVID+ cases (3.5%) have been nine years of age and younger, with an additional 127 in the 10-19 age group (8.2%), for a total of 182 (11.7%). 

Why are rates of infection low among kids?

There are several reasons. One, since kids are often asymptomatic or have very mild symptoms with COVID-19, many infections are never identified because they are not sick enough to test. In addition, even for symptomatic children, in many states, it is still very difficult to get tested, and some tests may take weeks to get the result.

Recently, there has been a lot of media attention on the increase in infections among children. This increase mirrors the increase in infections among adults overall. The rate of hospitalizations among children has gone down as the number of recorded infections has increased, so there is not an overall increase in the severity of the infection.

Even within households with COVID-19 positive cases, however, children are less likely to become positive for infection than adults in the same household. Across 10 different investigations of cases in five different countries, children under age 18 were about half as likely as adults to become positive if a family member was positive (15.7% of children vs. 31% of adults). Transmission (catching the COVID-19 virus) in a household with someone who is symptomatic is more than 25 times more likely than in a household with someone who is asymptomatic (20% vs. 0.7%). Using facemasks within the household when someone was sick was linked with lower risk infection and transmission.

There are several possible reasons why children don’t seem to be getting infected with COVID-19, and many studies are underway to figure it out. There are some interesting possibilities. One idea is that children may actually have some protection from getting sick with COVID-19 because they have some immunity due to exposure to other kinds of coronaviruses that cause the “common cold.” Children also overall have lower numbers of the receptors (ACE-2) that the virus attaches to in the nose and respiratory tract, which may change how they can be infected. 

How many kids are getting sick with COVID-19?

Compared to adults, children have lower rates of COVID-19 infection. Rates of hospitalization, needing intensive care and dying from COVID-19 are all also very low.

While hospitalization rates (hospitalizations/cases) are not reported by all states, they range from 0.4% to 4.6% of confirmed cases. Mortality rates (death) are from 0-0.3% of cases, among those states that are reporting. In the U.S., since July 30th, there have been a total of 86 confirmed COVID-19-related pediatric deaths. While some of these children had no apparent risk factors for being very sick from COVID-19, most had underlying conditions. 

As of August 24th, there have been only nine pediatric hospitalizations for COVID-19 out of 711 total in New Hampshire (1.3%), zero in Vermont and no deaths under the age of 20 reported in either state. 

Is MY child at risk for being really sick with COVID-19?

Based on those who have been sick enough to be hospitalized, there is only limited information on which children may be at higher risk for more severe illness. Current information suggests that children with medical complexity, including genetic, neurologic, metabolic conditions or with congenital heart disease might be at increased risk for severe illness from COVID-19. Similar to adults, children with asthma, diabetes, chronic lung disease, sickle cell disease or immunosuppression might also be at increased risk for hospitalization. Also, adults with obesity are at risk for greater disease severity, but this relationship has not been clearly established among children. We also know that children who are Black and/or Hispanic/Latino are at increased risk of hospitalization compared to white, non-Hispanic children. 

Additional resources

The Children’s Hospital at Dartmouth-Hitchcock (CHaD), has compiled a set of resources at CHaDKids.org to assist schools and communities in making decisions, with links to published guidance from the states of New Hampshire and Vermont.