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Purpose of review Pediatric Emergency Departments (PEDs) have experienced unique considerations throughout the coronavirus disease 2019 (COVID-19) pandemic. We review the adaptations and challenges surrounding the preparation and response for pediatric emergency patients, with a specific focus on operational modifications, evolving personal protected equipment (PPE) needs, protected resuscitation responses, clinical characteristics in children, and the unintended effects on children and youth. Recent findings COVID-19 has thus far proven to have a milder course in children, with manifestations ranging from asymptomatic carriage or typical viral symptoms, to novel clinical entities such as ‘COVID toes’ and multisystem inflammatory syndrome in children (MIS-C), the latter associated with potentially significant morbidity. It has had an important effect on primary prevention, injury rates, reduced presentations for emergency care, and increased mental health, abuse and neglect rates in children and youth. PEDs have prepared successfully. The most significant adjustments have occurred with screening, testing, and consistent and effective use of PPE, along with protected responses to resuscitation, adaptations to maintain family-centered care, and technological advances in communication and virtual care. Simulation has been key to the successful implementation of many of these strategies. Summary COVID-19 has pushed PEDs to rapidly adapt to evolving clinical and societal needs, with both resultant challenges and positive advances. Further experience and research will guide how in the face of a global pandemic we can further optimize the clinical and operational care of children and youth, ensure robust educational training programs, and maintain provider safety and wellness.