. 2022 Feb 1;36(2):435–479. doi: 10.1016/j.idc.2022.01.005

Table 4.

Definitions of acute COVID-19 severity and available treatment

Severity of COVID-19	General Definition	Pediatric Considerations	Treatment Recommendations
Asymptomatic infection	An individual who tests positive for SARS-CoV-2 but does not exhibit any symptoms over the course of the infection.	Diagnosis of asymptomatic or presymptomatic SARS-CoV-2 infections in infants and toddlers are reliant on clinical history gathering and specific questions to the child's caregiver. Symptoms may be subtle and difficult to ascertain in the nonverbal child.	Supportive care and ensuring caregivers and close contacts take appropriate precautions including encouraging SARS-CoV-2 vaccine uptake, if eligible. SARS-CoV-2–directed therapies should be used only in the context of a clinical trial.	Monoclonal antibodies are available by EUA to individuals ≥12 y and ≥40 kg who are at risk for severe disease,^a but preferably be used in the context of a clinical trial. The EUA for bamlanivimab-etesevimab has been extended to children of all ages including hospitalized children from birth to 2 y of age; with the Omicron variant, sotrovimab is the only approved monoclonal antibody with maintained efficacy against the new virus and should be administered within 10 d of symptom onset.
Presymptomatic infection	An individual who tests positive for SARS-CoV-2 and does not exhibit symptoms at the time, but then develops symptoms later in the illness course.		Supportive care and ensuring caregivers and close contacts take appropriate precautions including encouraging SARS-CoV-2 vaccine uptake, if eligible. SARS-CoV-2–directed therapies should be used only in the context of a clinical trial; when symptoms develop, treatment provided based on level of severity.
Mild	An individual who tests positive for SARS-CoV-2 and has signs or symptoms consistent with COVID-19, which may include fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, or change in sense of taste or smell. These individuals have no evidence of lower respiratory tract disease, including no shortness of breath, dyspnea, or abnormal chest imaging.	Children, particularly younger age groups, may also have nonspecific symptoms of feeding refusal, fussiness, runny nose, or nasal congestion.	Supportive care and ensuring caregivers and close contacts take appropriate precautions, including encouraging SARS-CoV-2 vaccine uptake, if eligible. Remdesivir and other therapies, including nirmatrelvir/ritonavir, should be used only in the context of a clinical trial; if remdesivir is used in an outpatient setting, this would be an off-label indication; molnupiravir is not approved for use in children, given concerns for interference with normal bone and cartilage development.
Moderate	An individual who tests positive for SARS-CoV-2 and has signs or symptoms consistent with lower respiratory tract disease, including shortness of breath or dyspnea or abnormal chest imaging. These individuals have normal baseline oxygen saturation typically ≥94% on room air.	In young children, a weak cry, grunting, tracheal tugging, nasal flaring, head bobbing, and sternal or intercostal retractions are additional indicators of respiratory distress, and may also suggest a lower respiratory tract infection.	Supportive care and ensuring caregivers and close contacts take appropriate precautions, including encouraging SARS-CoV-2 vaccine uptake, if eligible. Remdesivir and other therapies including nirmatrelvir/ritonavir should be used only in the context of a clinical trial; if remdesivir is used in an outpatient setting, this would be an off-label indication; molnupiravir is not approved for use in children given concerns for interference with normal bone and cartilage development.
Severe	An individual who tests positive for SARS-CoV-2 and has oxygen saturation <94% or below baseline, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (Pao₂/Fio₂) <300 mm Hg, respiratory rate > 30 breaths/min, or lung infiltrates >50%.	Radiographic abnormalities may be common in children and findings should be considered in the context of other symptoms, including hypoxemia. Normal respiratory rate by age group²⁶⁴: Newborn 40–60 breaths/min <1 y 24–38 breaths/min 1–3 y 22–30 breaths/min 4–6 y 20–24 breaths/min 7–9 y 18–24 breaths/min 10–14 y 16–22 breaths/min 14–18 y 14–20 breaths/min	1. Caregivers and close contacts take appropriate precautions including encouraging SARS-CoV-2 vaccine uptake, if eligible. 2. Remdesivir can be used as an antiviral in those with severe or critical acute COVID-19 weighing at least 3.5 kg. A multicenter pediatric COVID-19 guideline committee suggests using respiratory support requirement as the indicator for its use.¹⁷⁷ 3. Dexamethasone^b can be considered in critical disease, particularly in older age groups. 4. Interleukin-6 (eg, tocilizumab) or interleukin-1 (eg, anakinra) inhibitors can be considered in critical disease, preferably in the setting of a clinical trial.
Critical	An individual who tests positive for SARS-CoV-2 and develops respiratory failure, septic shock or organ dysfunction.	Careful consideration should be made to distinguish cases of critical COVID-19 and multisystem inflammatory syndrome in children (MIS-C). See Table 5.

Abbreviations: COVID-19, coronavirus disease 2019; EUA, emergency use authorization; SARS-CoV-2, severe acute respiratory distress syndrome coronavirus 2.

Risk factors based on the consensus by a multicenter panel of pediatric providers include children with medical complexity, young age less than 1 y, older age greater than 12 y, immunocompromised state, underlying severe cardiac or pulmonary disease, obesity, and diabetes.¹⁷⁷

If there is a concurrent condition for which steroids are indicated, steroids should be used as part of the treatment course (eg, asthma exacerbation).