Are children truly asymptomatic for COVID-19?

Children may require unique surveillance during the pandemic. While Covid-19 is known to threaten the older age, the question whether children are silent carriers remains unanswered. Only 2.4% of reported cases in China and 1.2% in Italy. It seems that children are infected by adults but it is unclear yet if children infect adults. The disease is less severe in children compared to adults with similar symptoms.1 Between 2-16% of children with Covid-19 were reported asymptomatic,2 with rates reaching 27% (in Israel3 So far, no reports identified transmission from an asymptomatic child. But are the children truly asymptomatic?

The variability of an asymptomatic report may be attributed to the extent of epidemiologic questioning. The asymptomatic children tend to be younger posing a further challenge in identifying epidemiological information.4 While young children are less likely to report pain symptoms, observational measures are routinely used.5 A similar approach should be used for retrieving covid-19 symptoms. The retroactive report is challenging. This may improve if parents could actively monitor and record symptoms in realtime. Australian symptom checker question about evident breathlessness symptoms such as: grunting and skin discoloration. Taking into account the asymptomatic cases we believe that active monitoring for mild change in behaviors will eventually reveal more symptoms. There is a consensus about remote assessment for adult covid-19 patients in the primary care setting.6 These recommendations could be modified and applied to children.

For example, asking the parents to note if their child has:

Low appetite: eats less, refuses favorite foods, less hungry, avoids solid food

Change in daily activities: things that the child did yesterday and is unable to do today.

Fatigue: plays for shorter periods, sleeps more than usual, fussier

Heavy breathing: new sounds, more parts are involved in breathing

Difficulty to speak: speaks less, shorter sentences, unusual pausing

Cough, drooling, runny nose, unusual skin color

In conclusion: Children may be underdiagnosed due to mild and under-reported complaints. Active surveillance maybe useful for the population at risk and/or before opening quarantines.



  1. Lu X et al. SARS-CoV-2 Infection in Children. NEJM 2020. doi: 1056/NEJMc2005073
  2. Livingston E and Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. JAMA 2020. doi:10.1001/jama.2020.434
  4. Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and Epidemiological Features of 36 Children With Coronavirus Disease 2019 (COVID-19) in Zhejiang, China: An Observational Cohort Study. Lancet Infect Dis 2020. doi: 10.1016/S1473-3099(20)30198-5
  5. von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain. 2007;127(1-2):140–150. doi:10.1016/j.pain.2006.08.014
  6. Greenhalgh T, Choon Huat Koh G, Car J. Covid-19: a remote assessment in primary care. BMJ 2020; 368 doi: