“Anyone who does anything to help a child in his life is a hero to me.”
Fred Rogers
“You many not control all the events that happen to you, but you can decide not to be reduced by them.” Maya Angelou
I’m an internist—a doctor who specializes in the care of adults -and a subspecialist in infectious diseases (ID). Some of my closest colleagues and friends practice pediatric ID. There are so many differences in how infectious diseases manifest in adults versus children that having two groups of ID subspecialists is warranted. COVID-19 is proving to be no exception.
Good news for those with children. With COVID-19, as well with most illnesses, you’re better off being young than old. A recent report in the journal Nature Medicine indicates that children and teenagers may be only half as likely to become infected with SARS-CoV-2 as adults who are 20 and older. And they usually don’t develop any symptoms (79% of infections in the under 20 age group are asymptomatic versus 31% of people older than 70).
Early in the pandemic the risk of dying if infected with SARS-CoV-2 was only 0.2% in the 10-19 year-old age group and was negligible for children between 0-9 years-of-age. This contrasted sharply with 80+ year-olds who had a case fatality rate of 14.8%. Many of us, however, have seen the concerning reports in the news about cases of COVID-19 in children. Yet, at present, children account for fewer than 2% of confirmed COVID-19 cases in the United States. Thus, it is important for parents to be armed with accurate information about what we know about how this disease impacts children—both physically and mentally.
Reports of an increase in child mortality. As the new coronavirus continues to spread throughout the United States, more reports of young people suddenly dying from COVID-19 are beginning to surface. Health experts aren't exactly sure why that's happening to some young patients as the disease causes only mild symptoms in most.
But, about 10% of children in the United States have asthma, and others have pulmonary, cardiac, neuromuscular or genetic diseases or are immunosuppressed. Just as for adults, all of these underlying health conditions increase a child’s vulnerability to more severe COVID-19. According to a recent analysis from the Centers for Disease Control and Prevention (CDC), “people with underlying health conditions are six times more likely to be hospitalized with severe COVID-19 illness and 12 times more likely to die of the disease than otherwise healthy coronavirus patients.” Pediatricians are on high alert for COVID-19. Like internists, they urge the same kinds of protective measures (wearing a mask, covering coughs and sneezes, frequent hand washing, avoiding crowds, and for now staying home from school).
Kids have milder COVID-19 illness. It is currently unclear why children generally have less severe COVID-19 than adults. As is the case in adults, the most common symptoms in children are fever (60%) and cough (65%). Also, as for adults, distinguishing COVID-19 from upper respiratory tract infections caused by other viruses is difficult if not impossible. In one case study of 20 pediatric inpatients from China which was published in the May issue of Pediatric Pulmonology, 13 (65%) had a history of close contact with family members with COVID-19. In these patients, evidence of bacterial co-infection was found in a majority, and distinctive abnormalities were common in chest computerized tomography (CT) scans.
Several theories have been proposed to explain why children don’t get so ill. These include that they have a more robust immune response to the virus. But a growing number of researchers think the difference between adults and children might relate to the condition of their blood vessels.
Many adults with serious COVID-19 experience clotting in their blood vessels leading to heart attacks and strokes. The clotting appears to be linked to a malfunctioning of the endothelium, the tissue that lines blood vessels, that prevents clotting in healthy individuals. Aging is associated with damage to the endothelium. This coupled with evidence that endothelial cells express ACE2 receptors, the target for the spike protein on SARS-CoV-2 that facilitates its entry into cells, seems to explain why severe COVID-19 in adults involves multiple organs, including the lungs, heart, brain, and kidneys.
Pediatric inflammatory multisystem syndrome. Children also do have a multisystem disease caused by SARS-CoV-2. It’s called pediatric inflammatory multisystem syndrome or PIMS. It is a distinct disease. And, it’s different from adult multisystem disease underscoring the point that infectious diseases manifest differently in children versus adults. On April 27, 2020, the Pediatric Intensive Care Society issued a health alert about PIMS associated with COVID-19. The alert was based on 15 cases in children in New York City hospitals.
PIMS is characterized by persistent fever and clinical features that resemble Kawasaki disease (KD), another illness that is primarily seen in children, and toxic shock syndrome (a disease caused by a toxin-producing strain of the bacterium Staphylococcus aureus). In addition to fever that was seen in all these pediatric patients, more than half reported rash, abdominal pain, vomiting, or diarrhea. A majority of the patients had low blood pressure requiring medications that increase blood pressure, and five required mechanical ventilation. None, however, died.
In May and June, the number of cases of PIMS in New York City increased. Similar reports on PIMS were issued from Italy, France, and the United Kingdom. In a June 8 publication in the Journal of American Medical Association, “Clinical Characteristics of 58 Children with a Pediatric Inflammatory Multisystem System Temporally Associated with SARS-CoV-2, ” Elizabeth Whittaker and her colleagues, reported the findings of 58 children hospitalized in England. The median age of these patients was 9 years. In addition to fever and nonspecific symptoms, rash was present in 30 of 58 (52%) and conjunctival injection (red eyes) in 26 (45%). Laboratory evaluation was consistent with marked inflammation. In total, 45 of 58 patients (78%) had evidence of current or prior SARS-CoV-2 infection.
Thirteen (22%) of these patients also met diagnostic criteria for KD, including 8 (14%) with coronary artery dilatation or aneurysms. While there was considerable overlap between PIMS and KD, the authors found a number of clinical and laboratory features that distinguished PIMS from KD and suggest PIMS is a novel syndrome. Intensive investigations are underway to determine the epidemiology and pathophysiology of yet another unique clinical manifestation of COVID-19.
Other health consequences of COVID-19 in children. Because of quarantining at home, children across the country, and for that matter around the world, have fallen behind schedule for critical immunizations, such as measles. A report in May co-authored by the CDC and the World Health Organization showed that “moderate-to-severe disruptions” or a total suspension of vaccination services in 68 countries affected 80 million children under the age of one.
As underscored by the CDC, the ongoing COVID-19 pandemic is a reminder of the importance of vaccination. When social distancing requirements are relaxed, children who are not protected by vaccines will be more vulnerable to diseases such as measles. In response, continued coordinated efforts between health care providers and public health officials at the local, state, and federal levels are necessary to achieve rapid catch-up in vaccinations.
In addition, COVID-19-related impacts on the mental health and development of children brought about by social distancing, school closures, economic hardships, and disruptions of family life can be profound. For useful advice, I recommend the CDC’s website, “Mental Health and Coping During COVID-19” (www.cdc.gov), and a May 15 commentary by Drs. Susan Swick and Michael Jelinek, “COVID-19 Quarantine: Managing Pediatric Behavioral Issues” posted on Medscape’s Coronavirus Resource Center.
On a positive note, one of the most remarkable differences between children and adults with all kinds of illnesses is how quickly kids bounce back. (You don’t need a medical degree to recognize that.) They are resilient. And they are responsive to change.
In my daily walks around the lake near my home, I see children doing the normal things that kids do in Minnesota in the summer—biking, skateboarding, kayaking, rollerblading, and jogging with their friends. While many are wearing masks and staying farther apart from each other, they are clearly still having fun. They’re not letting their childhood be reduced by this pandemic.
