As we head into year three of the COVID-19 pandemic, the updates and recommendations for how to stay safe from COVID, particularly for children, seem to be evolving as fast as a new variant in an unvaccinated population. (Sorry, pandemic humor.)
In all seriousness, as Omicron surges, the new guidance for children’s vaccines, boosters, masking, and school safety are moving so quickly that it’s hard for parents and caregivers to keep up.
The result is often pandemic-related confusion: Are cloth masks enough? When is it safe for kids to return to school based on symptoms and testing? Is COVID really as bad as or worse than familiar childhood ailments like the flu and RSV? And, most importantly, do parents really need to test a child for COVID every time they get a sniffle?
If you’re sick of asking people in the group chat or on the playground (and getting very strong and likely incorrect opinions), we asked some real experts for the answers to common questions.
Here’s what they had to say:
What are the COVID symptoms in children?
Children generally have symptoms just like adults, including a cough, fever, a runny nose, and sore throat. The latest development is that kids with COVID can often have croup, which causes a distinctive cough, hoarseness, and labored breathing.
“For many of the young kids I have been seeing, they present with croup,” said Dr. Jennifer Shu, an Atlanta-based pediatrician.
Sometimes the only symptoms in babies are fussiness and increased crying because COVID can make them achy and uncomfortable. “The baby may be crying and you can’t pinpoint a reason for it,” she said.
Children also get a loss of taste and smell, just like adults, but they may have more trouble articulating that than an adult would, said Dr. Dean Blumberg, chief of pediatric infectious diseases at UC Davis Children’s Hospital. In general, kids tend to have a less severe illness than adults.
How is Omicron affecting children?
Unfortunately, hospitalizations are on the rise for children, including babies and toddlers too young to be vaccinated.
In fact, hospitalizations are at the highest point since the start of the pandemic, according to CDC Director Rochelle Walensky.
My kid always has a runny nose, especially in winter. Do I need to get them tested every time they’re stuffed up?
Testing every kid for COVID every day is “just not practical,” said George Rutherford, a professor of pediatrics and epidemiology at the University of California, San Francisco. He doesn’t think children need to be tested for every runny nose unless they have an exposure or symptoms of “more severe upper respiratory infections.”
Blumberg agreed and said when it comes to testing kids, it's more important to focus on new symptoms; a child might have a runny nose due to allergies or something else.
“If you don’t think there is anything out of the ordinary with your child, then you don’t have to test because of symptoms such as a runny nose,” he said.
However, Shu recommends that given the current state of the pandemic, it’s a good idea to err on the side of caution and test children.
“We are seeing so much COVID compared to other cold viruses, even higher than flu in my area,” she said. “The vast majority of viruses I’m seeing are COVID.”
She added, “There’s a ton. COVID can look like any other respiratory illness.”
How accurate are rapid tests for young children under the age of 5?
Rutherford said there doesn’t appear to be any difference in how they perform for children versus adults. Rapid tests should work even when used in babies, experts told us.
That said, false negatives are common in rapid COVID tests early in an infection. You may need to retest after a negative result, particularly if a child has respiratory symptoms.
“The timing can be tricky,” Shu said. “If you don’t catch it on the right day where there’s enough virus to trigger that test to turn positive, it’s going to be a false negative.”
A positive result on a rapid antigen test is much more reliable in general (meaning if the result is positive, your child almost certainly has COVID if they also have symptoms), although following up with a PCR test to confirm is recommended.
How strong is the evidence that kids in preschool or at any age should be wearing masks?
The evidence for masking in preschool “is strong,” Rutherford said, as long as the child is over 2 years old, since there can be a suffocation risk for younger children. The data doesn’t come directly from preschools, but Rutherford said there’s “really good” evidence for the effectiveness of masks in elementary schools, and there’s no reason to think preschools would be different.
Blumberg said surgical masks provide 60%–70% protection, and he prefers those over cloth masks, which are less standardized. (Any mask is better than no mask.)
When Shu is choosing a surgical mask, she looks for one with an ASTM level 3 certification that is three- or four-ply, which tends to offer the best protection. Your child can use a medical mask and a cloth mask over it to be extra safe, or they can wear a KN95 or N95 mask if they can tolerate it.
While N95s come in smaller sizes and can be worn by children, they can be harder to breathe though, and it’s important to find a mask that fits well and that a child will actually wear.
“If they aren’t comfortable wearing it, they won’t wear it at all,” Blumberg said. Parents of children who are immunocompromised may prefer the greater protection that comes with an N95; some people, he added, buy several kinds to find one their child is comfortable with.
Kids often adapt to mask-wearing (and wearing them correctly) better than adults, he said. Letting kids choose and decorate masks can increase the chances that they will wear them.
Children may also play with the masks, get them wet by biting or chewing on them, or grow out of them more quickly than you’d think, Shu said, so it’s important to swap them out as necessary.
Some schools or preschools let kids come in with a negative rapid test, even when they have minor cold symptoms. Others require no symptoms for 24 hours and a negative PCR. Which policy makes more sense?
“You don't want colds passed around schools either, right?” Rutherford said. “But on the other hand, one of the reasons we have preschools is so parents can go work. That's a benefit of it. And if you send them home every time they sneeze, you're going to have a lot of unhappy parents.”
Rutherford said it makes sense for schools to continue to follow whatever pre-COVID sickness policies they had in place, with an added layer of COVID testing for children with more severe upper respiratory symptoms. But he said this testing should be rapid, not PCR, which usually takes multiple days to deliver results.
Blumberg said it’s “understandable” that schools would prefer that children who are having symptoms, like coughing, stay home until they are better.
“Schools may be extra sensitive to respiratory symptoms, even in a setting of a negative test,” Blumberg said. “It just makes everyone uncomfortable to be around somebody who is coughing or sneezing in the age of COVID.”
Shu recommends sticking to CDC guidelines if a child does test positive for COVID.
The CDC recommends that kids who test positive stay out of school for 10 days, which is a stricter guideline than for adults. The agency recently shortened the isolation period to five days for adults who are asymptomatic, followed by five more days of mask-wearing.
It’s a different story for kids, who are at school all day and have to take their masks off to eat lunch, exercise in gym class, and for other reasons.
“It’s not like they can continue to stay masked for the second five days of that 10-day isolation,” Shu said.
How long does COVID last in kids?
In general, COVD symptoms in children can range from very mild or nonexistent to more severe, such as a high fever or chest pain, which may necessitate a hospital visit for oxygen, depending on other risk factors and whether they are vaccinated.
The symptoms can last as little as one day, Shu said, but usually it’s about a week or sometimes even longer.
“A lot of my patients are having a cough linger for three to four weeks,” Shu said.
How worried should I be about my young kid getting long COVID?
More research still needs to be done to determine how often children — especially the youngest ones — get long COVID, which can make people sick for months.
Long COVID, which can include memory and sleep problems, fatigue, and shortness of breath, is more common in adults than children. And it’s more common in older children and teens than younger kids.
About 20%–40% of teens who get infected may develop long COVID, said Blumberg. “In younger children, it’s less, but we don’t have good numbers on that.”
However, the symptoms are similar in children and can include fatigue and difficulty sleeping.
“Older children will describe fuzzy thinking, that they are just not able to think clearly or they might have memory issues,” Blumberg said. “Those are the kind of long COVID symptoms we have been seeing in children.”
Shu has an 11-year-old patient who got COVID early in the pandemic and lost his sense of smell and taste for over a year.
Other children may not be able to be as active in sports as in the past because of chest pain, breathing problems, and shortness of breath, she said.
Where does COVID-19 fall on the scale of severity for childhood diseases? Is it more or less serious than the flu or RSV?
About 100 to 150 children die each year in the US from the flu, and 100 to 500 from the respiratory syncytial virus (RSV). In comparison, more than 800 children have died of COVID in the US since the start of the pandemic. About 7.9 million children in the US, or more than 1 in 10, have tested positive for COVID.
In 2020, COVID was the seventh-leading cause of death in children in the US.
“So it’s worse than RSV and worse than influenza,” Blumberg said. Part of the reason the mortality rate is so high with COVID is that no one in the population had any immunity to this new virus.
As more children get vaccinated for COVID (as we do for other diseases) or are exposed to the virus, hopefully, fewer children will get severely sick and die, he said.
“Getting vaccinated is the safest thing for children,” he said.
Is the COVID vaccine safe for kids?
Yes, it’s considered very safe. No children have died due to vaccination, unlike COVID, which, as we said, is potentially life-threatening.
More than 9 billion doses of vaccine have been given worldwide, so there’s a “proven track record,” Shu said, but only about 23% of children 5 to 11 have been fully vaccinated, and about 62% of children 12 to 17. The vaccine is now approved for children 5 and older, and kids 12 and older can get vaccinated and a booster.
“I am disappointed that the numbers are so low,” she said. Many children who are eligible are not getting vaccinated.
“Any loss of a child’s life is tragic, so why not try to avoid that?” said Shu, who is a spokesperson for the American Academy of Pediatrics. “I often have people say in hindsight, 'Gosh, I wish I had gotten the vaccine.' I’ve never had someone say, ‘Gosh, I wish I hadn’t gotten the vaccine.’”
How can you best protect babies and children who are too young to get vaccinated or wear masks?
As we said, masks aren’t appropriate for children under age 2, and kids under 5 can’t get vaccinated.
Most newborns will have some protection if their mothers have been vaccinated or infected.
Vaccination is highly recommended for people who are pregnant because of the high risk of COVID complications in pregnancy as well as the ability to generate antibodies that can be passed to the fetus.
“I don't think infants are susceptible until after 6 months of life because they get a lot of maternal antibody transplacentally and through breast milk,” Rutherford said. “Now, after 7 months, 8, 9 months, as maternal antibodies start to wane, we know of cases in young children, but they're not common at all.”
The best way to protect youngsters is to make sure the people around them wear masks, are vaccinated, and have had their boosters.
“Surrounding the baby with a ‘bubble’ of people who are vaccinated is a great first step,” said Dr. Danielle Zerr, head of pediatric infectious diseases at Seattle Children’s Hospital, in an email. “In addition, depending on community transmission rates, other steps would include avoiding crowds (especially indoors), limiting close interaction to just the important people in your life who are vaccinated, and avoiding contact with symptomatic people.”