Children and COVID-19

As a pediatrician in Tallahassee, Florida, I have only seen a few cases of Coronavirus in children. I have had no cases of COVID-19 in my pediatric office, Canopy Pediatrics, and until the last few days, I had only seen a handful of COVID-19 cases while working in the pediatric ER for Capital Regional Medical Center (and these were mostly teenagers). Only one child was ill enough to warrant a hospital admission, and this child probably had a severe complication of COVID-19 in children called “Multisystem Inflammatory Syndrome in Children,” (MIS-C) which I will discuss further below. Since I am gathering information for an interview with WTXL TV to discuss how children are affected by COVID-19, I decided to share what I’ve learned here:

First, let me paint an overall picture of the medical effects of COVID-19 on children. Like adults, children infected with COVID-19 experience “flu-like” symptoms (some or all of the following): fever, cough, sore throat, congestion, runny nose, body aches, and sometimes vomiting, diarrhea, and abdominal pain. Sometimes they can develop a rash.

So far, COVID-19 infections in children seem to be less common, less severe, and less contagious in children than in adults. I say “seem” for two reasons: First, compared to adults, children have been much more socially isolated than adults (for example, most schools have been closed since March, but many adults have continued working or going to the grocery store), so better social isolation than adults is definitely one contributing factor to fewer kids being infected with COVID-19. Second, new information is always being discovered about how children are affected by COVID-19 in children.

Children Have Less Severe Infection

Regarding severity, reviews of children have found that about 15% of COVID-19 infected kids will be asymptomatic and 80% will have some mix fever, cough, and congestion without a low oxygen level (Flu-like symptoms), and less than 1% will need to be hospitalized. Compare this to adults, where 1% of adults aged 20-49, about 5% of adults aged 50-59, and 18% of adults over 80 years-of-age infected with COVID-19 will require hospitalization. So, kids generally do pretty well with COVID-19.

But, even though the average child has a less severe COVID-19 infection, very rarely, in about 1 in 300 COVID-19 pediatric cases, a syndrome occurs called “Multisystem Inflammatory Syndrome in Children” (MIS-C). MIS-C usually occurs 1 to 3 weeks after the onset of the child’s COVID-19 illness or can even occur after an asymptomatic infection. I hope MIS-C does truly occurs in 1 in 300 children infected with COVID-19, because for me personally, it has happened in 1 of about 10 children that I have seen with COVID-19. As the name implies, many systems of the body are severely affected. Symptoms include high and prolonged fevers; headache, confusion, or seizures; heart abnormalities; abdominal pain, vomiting, or diarrhea; and skin rashes, sore throat, and pink eye. And to make matters worse, most of these children have negative nasal swabs for COVID-19, but have positive COVID-19 antibody blood tests, meaning that MIS-C usually occurs as a complication towards the end or after an infection with COVID-19. Treatment for MIS-C is currently under investigation.

Children Seem Less Contagious

Children (especially prepubertal children) seem to be less contagious and become infected less often than adults. Children of all ages can still get a serious COVID-19 infection, but most of the evidence points to children generally being less contagious. In studies, young children (less than 10 to 12 years of age) have been less likely than adults to catch Coronavirus whether they are at home, at school, or just living life. On the other hand, teenagers with Coronavirus are probably just as contagious as adults and just as likely to catch the disease. Much of this information comes from comparing high schools, middle schools, and elementary schools in the same town and by looking at whom gets infected in a household.

There have been recent stories of outbreaks among children at camps, especially overnight camps. This reiterates that even if everything is done correctly, many children will still become infected with COVID-19. But it also reiterates that given the right (wrong) circumstances, like singing in groups or sleeping in a one room cabin with teenage counselors, COVID-19 will quickly spread from child to child.

Additionally, on July 30th, in a JAMA Pediatrics article, investigators found higher levels of COVID-19 viral RNA in children’s nostrils compared to COVID-19 positive adult noses. The clinical significance of this finding is yet to be seen. Many pediatricians think that since kids are not getting tested as much as adults (as many COVID testing sites will not test kids), the children in this study might have been more sick than the adults.

Why Are Children Less Affected?

So why is COVID-19 generally less severe in children than adults? Scientists are considering a few possibilities. One is that nasal tissue of younger children (less than 10 years of age) have less of the “ACE2” receptors that COVID-19 uses to enter into cells. A second possibility is that children have a less intense full body inflammatory response than adults. A third possibility is that children commonly co-infected with other viruses, and maybe other viruses are “running interference” leading to less COVID-19 virus production. And a fourth possibility is simply that children have relatively healthier blood vessels than adults.

How Are Different Ages Affected?

So, how are different ages of children affected? First, it does appear that children under 1 year-of-age, particular infants less than 3 months-of-age, are more susceptible to the effects of COVID-19 than older children. A few studies have shown an increased hospitalization rate in this age group. Also babies with Coronavirus may not have the typical fever, cough, and congestion of older children, but rather may present with trouble eating or fussiness.

Now the safest age to be right now is between 1 and 10 years of age. Many studies have shown that this age group is the least likely to get infected when exposed to COVID-19, the least likely to have serious illness from COVID-19, and the least likely to spread COVID-19 if infected. This may be because this age group has less ACE2 receptors than adults AND has a stronger body and immune system than an infant. But it is this age group that generally gets the severe MIS-C.

There is still some question as to whether kids over the age of 10 (tweens and teenagers) are less susceptible to COVID-19 than young and middle-aged adults. A few large studies, where large groups of people were swabbed, found similar rates of COVID infection in children 10-18 as adults. But, studies do show that teenagers are hospitalized less often than young adults. This could simply be that teenagers are less obese and have less chronic conditions than young adults.

So practically what does this mean?

First, for parents of infants or are pregnant: COVID-19 is more dangerous in babies than older children, so these parents should be extra careful to limit potential exposure to COVID-19, especially during the first three months of a baby’s life. These families should limit visitors and require that all visitors self-quarantine for 14 days before spending time with the baby. They can also limit the infant’s exposure to COVID-19 by finding a pediatrician who allows families to wait in the car (rather than a waiting room) or who provides home visits.

Second, for social interaction outside of school: Children, and their parents, are going crazy, not being able to interact with their friends and family. I think this data supports the idea that occasional close social interactions between toddlers or school-aged children (prepubertal kids) of different families (whose parents are otherwise being careful to social distance and do not have chronic conditions themselves), may be worth the risk for some families (as long as the parents keep their distance from each other). For many families, the low (but still substantial) risk of infection may be worth the trade-off for quality social interaction for their children. But again, the parents would need to practice good social distancing, so that they don’t accidentally infect each other.

On the other hand, close social interaction between kids over the age of 10 is more risky, which is too bad, because this is the age group that really needs social interaction. If kids of this age get infected, they will most likely do well themselves, but they are at high risk of passing the infection to siblings, parents, or other friends, which will lead to worsening of the COVID-19 outbreak.

And last, there is always the risk of a child developing COVID-19 Multisystem Inflammatory Syndrome in Children (MIS-C). As I mentioned earlier, scientists think it only occurs in 1 in 300 children infected with COVID-19, so hopefully my experience with MIS-C will not be the norm.

How Can Families Medically Prepare?

To be ready for this fall and winter, families need to have a pediatrician or family doctor that they can easily reach, and that they trust. When a child develops symptoms of a possible COVID-19 infection, this first thing to do is call or text your primary care physician for guidance.

And families can rest assured that Tallahassee has great emergency rooms and hospitals, like CRMC and TMH, that are prepared to evaluate their child in case of severe or concerning symptoms.