Update: Children and COVID-19

Following this week's news of a 90% increase in the number of COVID-19 cases among U.S. children over the last four weeks, a lot of parents are asking if their youngsters need to mask up.

The answer: It depends.

Priya Soni, MD, a pediatric infectious disease specialist at Cedars-Sinai, says children under the age of 2 are not required to have masks on in public.

But for children older than 2, Soni said, "leaving the house means masking up."

The reason masks are not as crucial for infants and younger children is because their airways are smaller, making breathing through a mask more difficult. Younger children have also been found to be less likely to spread COVID-19 because their smaller airways mean they have less ability to spread large respiratory droplets to adults.

"However, newer studies show that older children and teens can transmit the virus as effectively as adults," Soni said.

There also are differences in symptoms between younger and older children.

Older teens ill with COVID-19 have the same symptoms as adults – including coughing, shortness of breath and fever. But younger children experience different symptoms, like fatigue, runny nose, muscle aches, vomiting and/or diarrhea.

"These symptoms, unfortunately, mirror many other childhood illnesses, so it is important for parents to be in communication with their pediatricians," Soni said. "Often, video visits can do the trick."

For example, a pediatrician may be able to determine whether a child has seasonal allergies or something more worrisome just by seeing the patient via a video visit.

“As physicians, we are having to rely on our observational skills even more in the digital age," said Soni. "We are sharpening our skills to synthesize what the child isn’t saying to us. Luckily, in pediatrics, most of us do this constantly and we feel comfortable guiding families through a difficult time, even via virtual visits.”

During the most recent uptick in COVID-19 cases in California, Cedars-Sinai saw an increase of children and teens coming to the Emergency Department. Although many tested positive for COVID-19, in general, pediatric patients required fewer hospitalizations.

The reasons for this are likely due to multiple factors, such as the levels of ACE2 (angiotensin-converting enzyme 2) receptors in young children, especially those 4-9 years of age. ACE2 receptors are the doorways that allow the virus that causes COVID-19 to enter the body and eventually go to the lungs. Recently, it has been found that children do not have as many ACE2 receptors in the nasal tract, which might confer some protection against COVID-19 entering the body and causing damage.

"Generally speaking, the lungs of children are younger and healthier than adults' lungs," Soni said. "We also believe that their immune systems may be primed to handle viruses better because of the frequent vaccines children receive in the earlier years."