In COVID hot spots across the country, numbers point to a disturbing trend: dramatic spikes in infections among children and teenagers.

In Michigan, which became an epicenter of the spring surge, state data showed big jumps in cases among kids and teens 19 and under. As COVID-19 vaccinations increase, cases are just beginning a downward trend in the state.

While severe complications from COVID-19 in kids is still rare, youth transmissions may be playing a bigger role in community spread now compared to earlier in the pandemic, according to experts at Michigan Medicine C.S. Mott Children's Hospital.

Many factors are behind what health officials have called the perfect storm during this surge: Young people, some who aren't able to get vaccinated yet, have resumed many in-person activities, like sports, just as an increasingly contagious strain of the coronavirus becomes dominant and states have reopened.

Mott associate hospital epidemiologist Terri Stillwell, M.D., M.P.H. and Prashant Mahajan, M.D., M.P.H., M.B.A., vice chair of the Department of Emergency Medicine and chief of Pediatric Emergency Medicine at Mott, explain more behind the pediatric trends and what parents should know.

What kinds of COVID infection increases are we seeing in kids?

Many states reported that youth cases contributed to the recent COVID surge, but that isn't surprising given overall increases among all ages during this wave of the pandemic, Mahajan says.

During a seven-day average in mid-April, Michigan saw a daily average of 827 cases among ages 10-19 and 285 cases for ages 0-9 – a roughly quadruple increase for each age group compared to a weeklong average in mid-February, state data suggests.

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That compares to a daily average of 1,123 cases for ages 20-29 and 935 cases for ages 30-39 during that same week in April – with these age groups also seeing dramatic increases in COVID infections over recent months.

"We believe these spikes in pediatric cases reflect the global increase we've seen in our communities," Mahajan says.

What are children's risks of COVID complications?

Pediatric hospitalizations from COVID are also up across the country and in Michigan, Mahajan says, which has concerned many health officials.

But these numbers also appear to be a reflection of the overall increase in pediatric and youth infections. Earlier in the pandemic during state shutdowns, quarantines and school closures, children and teens generally had less community exposure.

The uptick doesn't necessarily mean the new COVID strain is more potent against children, with serious disease in pediatric patients still rare, Mahajan says.

However, a relatively small number of children do develop severe or longer term symptoms from COVID. Children with underlying conditions are considered at higher risk of serious complications, including those with asthma or chronic lung disease, diabetes, genetic or neurologic conditions, sickle cell disease, congenital heart disease, obesity, a weakened immune system or medical complexity.

But in other instances, previously healthy children are experiencing complications too, including an extremely rare but potentially life-threatening COVID-linked condition called multi-system inflammatory syndrome, or MIS-C. And more states are reporting cases of MIS-C, which causes severe inflammation in vital organs and tissues.

Other kids are experiencing lingering symptoms long after a COVID infection, including respiratory issues and fatigue.

"The problem is we can't yet predict which children are more likely to suffer serious COVID symptoms," Mahajan says. "That makes it especially important for adults around them to get vaccinated, continue following safety precautions like masking and social distancing and helping enforce these measures among young people too."

Are children and teens more likely to get infected with the new strain?

"There isn't any data suggesting that kids are necessarily more susceptible to new strains of COVID, but the B.1.1.7 variant itself is more transmissible overall," Stillwell says. "People have also developed pandemic fatigue and may not be as diligent as they used to be, at the same time that more places have opened up and in-person activities have resumed."

While older people are more likely to have been vaccinated earlier, younger people remain vulnerable to infections, Mahajan says. The COVID vaccine became available to everyone 16 and older in April and is expected to expand to the 12-15 age group this summer.

"Vaccines haven't reached many youth and aren't yet available to kids who are now out in the community more than they were before," he says. "It's a game of catch up, with the vaccination rollout initially focused on the elderly who are at highest risk of getting severely sick."

What are the sources of exposure for children, adolescents and teens?

Many of the COVID clusters and outbreaks involving teens especially have been traced back to extracurricular activities, youth sports, social gatherings or trips – such as spring break – versus exposure during in-person school or from the classroom.

"The problems aren't necessarily the practices or games themselves or what's happening during school hours. It seems to be more about how youth are interacting before and after events, possibly gathering indoors or eating together without masks, for example," Stillwell says.

"Young people may also be less vigilant in instances without adult supervision. They may get comfortable with their buddies and sit close together in the dugout or share snacks or water bottles for instance."

And those types of outbreaks are disruptive to schools trying to keep in-person learning open. A positive COVID case stemming from a personal gathering or the community means that not only does that child need to quarantine – but so too does any classmate who may have been exposed. That's why even a few positive cases in a school building can lead to large masses of children having to miss school regardless of symptoms.

When schools close due to these cases, headlines may mislead people to think exposures happened at school. But families should be most mindful of young people's behaviors outside of the school setting, Stillwell notes.

"Kids have more structure at school. They stand in line, likely have assigned seats in class, have to follow certain rules about eating in the cafeteria and adults are enforcing mask-wearing and other mitigation measures," Stillwell says. "It's the times when kids are on their own and kind of left to police themselves that they're probably at the highest risk of exposure."

Are children efficient spreaders of COVID?

Experts are still learning about children's role in spreading COVID. Previous data suggests that household infections are generally less likely to be traced to children, with adult-to-child transmission much more common than child-to-adult spread, Stillwell says.

This data was used to inform some decisions about how to safely reopen schools in some parts of the U.S.  

Still, "we know that children can both get and spread COVID, so public health interventions addressing this population are important," she says.

How can parents help minimize the risk of COVID for kids and teens?

1. Encourage socially distanced activities

There are many emotional health benefits to socialization among children and teens, as well as growing concerns about how isolation may impact youth mental health, experts say. But parents should encourage safe ways to see friends.

Mahajan and Stillwell recommend outdoor activities that involve mask wearing and social distancing, such as bike rides or walks.

"Avoid indoor gatherings, such as sleepovers, which may involve multiple households and situations that involve eating and less consistent mask use," Stillwell says.

2. Model the behavior

Kids are strongly influenced by those around them. If adults show they're growing weary of mask wearing by wearing them less often or improperly, their children will notice.

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"Adults should reinforce the importance of mitigation measures that will help us end this pandemic through leading by example," Mahajan says.

3. Don't let your guard down

Because the virus can take a few days to show symptoms, it may feel safe to get a little too comfortable with people you know if they don't look sick, Stillwell says.

"Because of the long infectious period, people can feel completely fine but still be infected and contagious. This can give people, especially youth, a false sense of security when they're around close contacts," she says.

"It's human nature to want to be close to your friends. But the virus doesn't care if that's your best friend. It's important to remind kids and teens that social distancing is always important, even if their peers look healthy."

4. Check on COVID precautions before sports, camps or vacations

Stillwell recommends parents ask questions about how sports organizations and summer camps enforce COVID precautions. For camps, it's important to know where children eat, for example, and the plan for managing an exposure and health screenings. For sports, it's making sure teams are enforcing mask-wearing and have a communication plan for letting parents know about exposures and what it means for teammates.

For families planning vacations, minimizing crowd exposure is still best, especially if the whole family hasn't been able to get vaccinated. A road trip involving a house rental may be among the safest choices.

5. Beware of unstructured times

Families should be mindful of how their kids are interacting with peers during unstructured, unsupervised times, whether it's on the sidelines of a game or in between scheduled extracurricular activities.

"Young people are out socializing more and the disease is more prevalent in that space. People are tired and young people especially are excited about finally getting back to somewhat regular kid life," Mahajan says. "This is the time to increase messaging about the importance of vaccination and continuing to follow safety measures."

Parents should also talk to their kids ahead of social situations to remind them about proper mask use – that it doesn't count if it's hanging below your nose or chin for example – and why it's important to say vigilant even when adults aren't around.

"We've gone this long and are glad to be able to resume some activities using new safety measures we know work in minimizing exposure and spread," Stillwell says. "But we need to hold off a little longer before we can return to socializing the way we used to."