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Last reviewed: July 6, 2022
As of June 2022, FDA has granted emergency authorization for Pfizer-BioNTech COVID-19 vaccination in children ages 6 months–15 years and for Moderna COVID-19 vaccination in children ages 6 months–17 years and CDC's Advisory Committee on Immunization Practices has issued clinical recommendations. Pfizer-BioNTech COVID-19 vaccination for adolescents ages 16–17 years received full FDA approval in August 2021. For more information on the specific authorizations and recommendations for COVID-19 vaccines in pediatric populations, visit our mRNA Vaccines page; refer to our Vaccine Dosing and Schedule page for details about pediatric administration.
CDC and the American Academy of Pediatrics recommend COVID-19 vaccination in all eligible children and adolescents. For more on the safety of COVID-19 vaccines in children, visit our Vaccine Safety page, which includes resources on myocarditis.
Although children have experienced lower rates of severe COVID-19 compared with adults, they are still at risk for severe disease (including delayed complications such as multisystem inflammatory syndrome in children, or MIS-C) and can transmit SARS-CoV-2 to others. Initial clinical trials of COVID-19 vaccines excluded children and adolescents, but there are ongoing studies of all currently authorized vaccines (either fully approved or under emergency use authorization) in these patient populations (Hause, May 2022 – preprint, not peer-reviewed; Pfizer-BioNTech FDA Briefing Document [PDF]; Moderna FDA Briefing Document [PDF]).
Key pediatric vaccination resources
- American Academy of Pediatrics Resource Hub: COVID-19 Vaccine for Children
AAP’s comprehensive collection of guidance and resources for clinicians on pediatric COVID-19 vaccination and communicating about vaccines with families and communities.
- COVID-19 Vaccines for Children and Teens
CDC information on COVID-19 vaccinations for children and teens, including eligibility details and information about how to find vaccines.
- Interim Recommendations for Moderna and Pfizer-BioNTech COVID-19 Vaccines in Children Aged 6 Months–5 Years
Clinical guidance from CDC’s Advisory Committee on Immunization Practices.
- Interim Recommendations for the Use of Pfizer-BioNTech COVID-19 Vaccine in Children Aged 5–11 Years
Clinical guidance from CDC’s Advisory Committee on Immunization Practices.
- How to Talk with Parents and Caregivers About COVID-19 Vaccination
CDC guidance for clinicians on counseling parents and guardians about the importance of pediatric COVID-19 vaccination.
What is the burden of SARS-CoV-2 infections in children?
Nearly one in five diagnosed COVID-19 cases in the U.S. has been in children ≤18 years of age, mirroring the proportion of children in the U.S. population (22%) (CDC COVID Data Tracker; American Academy of Pediatrics, June 2022). Additionally, at least 75% of U.S. children show antibody evidence of prior SARS-CoV-2 infection, signifying high underreporting of infections in this group (Clarke, April 2022). Infections in children tend to follow community transmission rates, and these rapidly increased during the Omicron variant wave, with >5 million children infected between January and March 2022 alone (American Academy of Pediatrics, June 2022). In addition to directly causing physical illness, the COVID-19 pandemic has had far-ranging impact on the health and wellbeing of children due to disruption of normal care cascades and social networks (Saunders, February 2022; Patrick, October 2020; Racine, August 2021; Chaffee, May 2021; Pelham, September 2021).
How frequently can children transmit SARS-CoV-2 to other children and family members?
Children with COVID-19 appear to develop similar viral loads in the nasopharynx as adults and are capable of transmitting SARS-CoV-2 to other children and adults (Chung, June 2021). Several studies indicate the possibility of outbreaks among children in congregate settings such as summer camps, as well as transmissions within the home; there is no evidence that younger children are less likely to transmit or avoid infections than are adolescents (Baker, March 2022; Chu, September 2021; Paul, August 2021). Transmission events have occurred in schools, both among students and from teachers, and guidance to support best practices to reduce the spread of COVID-19 and maintain a safer learning environment has been developed by both CDC and the American Academy of Pediatrics. There is not strong evidence that the opening of schools is itself a primary driver of community COVID-19 outbreaks (Choe, February 2022).
Which children are at highest risk for developing severe COVID-19?
Although COVID-19 mortality remains very low for most children (<0.04% case fatality ratio), 2%-3% of diagnosed cases have historically resulted in hospitalization, of which 20%-30% included intensive care unit admission (COVID-NET; Götzinger, September 2020; Kim, August 2020; Moreira, January 2021). Over 1,000 U.S. children with a diagnosis of COVID-19 have died (CDC COVID Data, May 2022).
Severe COVID-19, including hospitalizations, appear more common in children under one year of age and among those with one or more significant comorbidities, such as diabetes, immunocompromise, chronic pulmonary or cardiac disease, neurodevelopmental disorders and obesity (prevalent in 20% of U.S. children) (COVID-NET; Graff, April 2021; Dong, June 2020; Kompaniyets, June 2021; Marks, March 2022). Across age groups, children who are not vaccinated against COVID-19 are also at higher risk of suffering severe COVID-19 and its complications, including MIS-C. Additionally, as in other age groups, children of Black or Latino ethnicity may be at higher exposure risk for SARS-CoV-2 infection and thus suffer a disproportionate burden of severe outcomes (Dennis-Heyward, June 2021; White, June 2021; Marks, March 2022).
Notably, hospitalizations among children with COVID-19 during the first U.S. Omicron wave rapidly increased, particularly among the group of unvaccinated children <5 years of age. More than 50% of these children did not have known underlying medical conditions (Fleming-Dutra CDC Presentation, June 2022 [PDF]), yet nearly25% ultimately required ICU-level care.
MIS-C is a rare, Kawasaki-disease-like multi-organ syndrome that has affected >8,500 U.S. children and resulted in 69 deaths, according to CDC data. Diagnoses follow rises in community COVID-19 counts, and nearly all children show evidence of SARS-CoV-2 infection or an epidemiologic link to a person with COVID-19 within the prior 2-6 weeks. In contrast to severe COVID-19, MIS-C predominately affects school-aged children (ages 5-13). Nearly two-thirds of U.S. MIS-C cases have occurred among Black and Latino children (Payne, June 2021); this ethnic distribution may reflect overall disparities in COVID-19 burden or may involve other biological factors.
MIS-C commonly involves prominent cardiovascular injury including myocarditis and coronary aneurysms that require intensive care, while mucocutaneous and gastrointestinal manifestations are also more common than in other severe COVID-19 illness. The syndrome is characterized by very high levels of inflammation (Feldstein, February 2021; Lee, July 2020). High-dose intravenous immune globulin has emerged as a mainstay of treatment and is included in AAP interim guidance. Adjunctive corticosteroids have been possibly associated with improved treatment response in observational analyses (Ouldali, February 2021).
The pathophysiology of MIS-C remains uncertain, but the marked levels of observed inflammation are associated with multiple dysregulated arms of the immune system, differing in several ways from signatures in severe COVID-19 without MIS-C (Diorio, July 2020). This includes activation of the inflammasome and associated cytokines such as interleukin 1ß, interferon signaling and other markers of macrophage activation, complement and coagulation cascades (Wang, July 2021; Akindele, August 2021; Sacco, February 2022; McCafferty, May 2022). Several markers of B- and T-cell activation also appear to be upregulated, demonstrating altered homeostasis, possibly related to a superantigen-like interaction of viral proteins with host immune cells (Porritt, March 2021). It is not known if certain genetic factors such as human leukocyte antigen type underlie predisposition to developing MIS-C after SARS-CoV-2 infection.
What are the recommended treatments for children who develop COVID-19?
A variety of therapeutics have been authorized or approved for COVID-19 treatment in children, primarily focused on early treatment for the subset of children who are at higher risk of progression to severe disease. Many drugs receiving FDA emergency use authorization for COVID-19 include authorization for use in children ≥12 years of age and ≥40 kilograms, based upon extrapolation from studies in adults. This includes the oral antiviral nirmatrelvir/ritonavir (Paxlovid) and the intravenous monoclonal antibody bebtelovimab. Due to sparse clinical safety and efficacy data, including lack of comparative data in high-risk patients, use of bebtelovimab is generally recommended for children who are not candidates for alternative therapies.
The intravenous antiviral remdesivir is FDA approved and has been formally studied in very young children; weight-based dosing is therefore approved for treatment of any disease severity in children ≥28 days of age and weighing ≥3 kg. In contrast, the oral antiviral molnupiravir is contraindicated in children under 18 years of age due to toxicity concerns in juvenile animal studies.
Outpatient antiviral drugs should be given early in disease and are authorized for children with mild-to-moderate COVID-19 (i.e., not requiring new or increased oxygen from baseline). Nirmatrelvir/ritonavir is authorized to be given within 5 days of symptom onset for a 5-day course, whereas single-dose bebtelovimab should be given within 7 days of symptom onset. Remdesivir is FDA approved to be given as a 3-day infusion within 7 days of symptom onset for mild or moderate disease, or as a 5-day course (with extension up to 10 days for critical disease or lack of clinical improvement) for severe or critical disease.
Additionally, for children ≥12 years of age and weighing ≥40 kg with moderate-to-severe immunocompromise and either anticipated poor vaccine response or absolute contraindication to vaccination, pre-exposure prophylaxis with the injectable monoclonal antibody combination tixagevimab and cilgavimab (Evusheld) is authorized as COVID-19 prevention (but not for treatment or post-exposure prophylaxis).
Can children experience post-acute COVID syndrome/Long COVID?
The incidence of post-acute symptoms in children who have had COVID-19, (i.e., persistent symptoms lasting >1-3 months following onset of COVID-19 symptoms or diagnosis) is an area of active investigation. Interim AAP guidance addresses follow-up care of infants, children and adolescents after a SARS-CoV-2 infection.