How COVID-19 Is Bad for Kids

What the Newest Science Tells Us

If there’s anything that the COVID-19 pandemic has taught us, it’s that what’s true one day will be outdated the next. Can we still feel confident that COVID-19 doesn’t significantly negatively impact the health and well-being of children?

 

Many Facets of Kids Health

Again and again during the pandemic, with vastly differing sources and quality of evidence, parents have heard that COVID-19 isn’t bad for kids. But what exactly does this mean? 

In terms of the physical illnesses that children can experience from the novel Coronavirus (SARS-CoV-2), this comes in three flavors: 

1. Acute respiratory COVID-19
2. Multisystem Inflammatory Syndrome in Children (MIS-C) 
3. Long COVID

I will describe these illnesses, which DIRECTLY impact the health of children, below. Children have suffered greatly during this pandemic, mostly because of INDIRECT byproducts of COVID-19 on the functioning of families and society at large. These indirect forces on children include structural changes in education, socialization, and the subsequent physical and mental illness within their families. Far more than direct illness, the indirect impact of COVID-19 on children is massive, and is generally more difficult to measure.

 

Acute Respiratory COVID-19 in Kids

From early on in the pandemic, it was pretty clear that the younger you were, the less severe your illness would likely be if you contracted SARS-CoV-2. As the virus made its way around the globe, reports said much of the same: the older you were, or the more underlying chronic health conditions you had such as cardiac, respiratory or metabolic disease (think diabetes and obesity), the more likely you were to be hospitalized or die from COVID-19. When the virus surged in the US in March 2020 onward, we observed similar trends. 

Mounting data on pediatric COVID-19 came in later in 2020 as more and more children tested positive for SARS-CoV-2. Early in the pandemic in the US, the hospitalization rate for kids from COVID-19 was a fraction of what is commonly observed with common seasonal pediatric viral infections, including respiratory syncytial virus (RSV) and influenza (“flu”), which usually account for the majority of pediatric hospitalizations every year. As the year progressed and novel variants of concern moved through the United States, that picture changed some. In the Spring of 2021, pediatric medical providers diagnosed and managed far more COVID-19 in children from infancy to older teen years. While the overall likelihood of hospitalization and severe disease from COVID-19 was maybe only a few percentages higher with the B.1.1.7 variant compared to the initial variant, we suddenly observed more children needing intensive care for their acute respiratory COVID-19. As the Delta variant emerged in the US in the summer of 2021, we saw children and adolescents, the largest unvaccinated population in the world, taking on the lion’s share of new COVID-19 cases. The hospitalization rate due to Delta has remained about the same as other COVID-19 variants (low single digits). Yet, children’s hospitals have been overflowing in the second half of 2021 due to the sheer volume of COVID along with other respiratory viruses that have re-emerged. In sum, we have learned that while severe disease and hospitalization were not common for children when they contracted this virus, it could still happen to some. We are currently learning about the spectrum of disease the even more contagious Delta variant can cause in children. 

One early report of COVID-19 in children in the U.S. highlighted an important risk factor for severe disease, including admission to an intensive care unit and respiratory failure requiring a ventilator: obesity. Some of the groups of children whom we angst over quite a bit, including those with compromised immune systems and higher risk of severe respiratory infections (including children with cancer, congenital heart disease, solid organ or bone marrow transplantation, cystic fibrosis) seemed to fare much better from acute respiratory COVID-19 that we thought they would. At first, we thought this was because these groups of people completely isolated themselves from society; but later as more children with these predicted higher-risk conditions contracted SARS-CoV-2, they did not get severely ill from COVID-19. Even newborn babies, long-thought to be at very high risk for getting very sick from all sorts of viral and bacterial infections, beat the odds when it came to severe COVID-19, with rare exceptions. 

So, we in the pediatrics have been left to wonder: why is this the case? Children generally have the higher burden of severe disease with so many other viruses and common communicable bacterial infections, so why has COVID-19 proven to be so different? The short answer is: we don’t really know yet. There are some accepted hypotheses that haven’t been fully tested yet, including: 

1. Children, who suffer the largest burden of “common colds”, are regularly infected with circulating seasonal Coronaviruses; leading to higher immunity to this family of viruses, making their immune systems better equipped to combat SARS-CoV-2..
2. The SARS-CoV-2 virus needs to interact with a cellular receptor to enter a human cell and cause an infection, ACE-2, which is less-abundant in children. 
3. Children have healthier hearts, lungs, and blood vessels, making the onslaught of inflammation caused by COVID-19 less dangerous. 

None of these hypotheses have been proven, but they’re interesting to think about. Each time a novel variant of concern marches across the globe, we become  anxious to see if each variant will also have less disease severity in children.  

Unfortunately, COVID-19 can make some kids very ill. Children with COVID-19 may have no symptoms, or feel like they have the common cold (runny nose, cough, fever, sore throat). Relatively few children develop more significant respiratory issues including difficulty breathing and low oxygen levels that require care in the hospital, and the hospitalization rate for COVID-19 in kids in the US has ranged from 0.1-2%. Some children get ill enough to need care in the intensive care unit to support breathing with a ventilator, and pediatric deaths from COVID-19 are rarer still. This is not to say that we should ignore the role that children (who make up 25% of the human population) play in the shape of the COVID-19 pandemic. More on that later!

 

Multisystem Inflammatory Syndrome in Children (MIS-C) 

The flip side to acute respiratory COVID in children is the condition dubbed MIS-C (or Pediatric Immune Modulatory Syndrome, a.k.a. “PIMS” if you practice medicine in the Eastern hemisphere), described in the Spring of 2020.

This mouthful of a diagnosis, MIS-C, is, fortunately, a rare consequence of having been infected with SARS-CoV-2. Still, it is a very important condition to diagnose because children can become catastrophically ill with this condition. This syndrome can affect children of any age, gender, race, or socio-economic status, and it can happen even after a child has minimal or even NO symptoms of COVID-19. MIS-C usually develops two to eight weeks after the initial SARS-CoV-2 infection, with occasional overlap between acute respiratory COVID-19 and the “post-inflammatory” MIS-C. There is much speculation about why and how this syndrome develops, and researchers are trying to understand this phenomenon. We simply don’t know all the answers yet. 

The strangeness of this diagnosis is in synchrony with the strangeness of the symptoms that most children with MIS-C exhibit. Very few have the tell-tale respiratory symptoms seen in acute respiratory COVID-19. Instead, children have fever for at least a day, with any of these other symptoms: any sort of rash on the body, swelling of the lymph nodes (or “glands”) in the neck, abdominal pain, vomiting or diarrhea. Occasionally a child is more lethargic or has swelling of their hands/feet. MIS-C can actually superficially look much like many other infections in children (like a stomach flu), but in this day and age, many children who even could have MIS-C are admitted to the hospital to be evaluated and until their diagnosis is more certain. The reason to be so medically cautious is that children who have MIS-C can become extremely sick in a short period of time, and it’s safest to have the child monitored in the hospital so that the best care can be given in the moment. Luckily, the majority of children with MIS-C, when given prompt medical therapy, recover quickly, and the risk of death and permanent disabilities is low compared to adults hospitalized with COVID-19. However, if diagnosis and treatment is delayed, or the case of MIS-C is complicated enough, children can die from the condition. As of July 2021, in the US 37 children have died from MIS-C. 

 

Long COVID

The long-lasting effects of COVID-19 on children and adults can be some of the most challenging to manage. “Long COVID” is a spectrum of issues that people can experience for months after they recover from acute respiratory COVID-19. Long COVID can include brain fog, difficulty thinking and processing information, exercise intolerance, abnormal changes in blood pressure when going from seated/lying to standing up, physical deconditioning, and persistent shortness of breath. There are widely varying estimates of what proportion of those who had acute COVID-19 go on to suffer Long COVID, ranging from single percentages up to 50%! Taking the many reports together, “safe” estimate is that Long COVID occurs in 5-10% of children affected by acute COVID-19. So in many ways, Long COVID, while not as much of an acute medical concern, can cause the most disability in children when it comes to the direct medical effects of COVID-19. 

For young athletes, Long COVID can be a particular challenge, as they may require clearance from a cardiologist before resuming sports. Also for our athletes, it's incredibly important to note the direct damage to heart muscle, termed "myocarditis" occurred in 2.3% of Big 10 college athletes, which can predispose them to life-threatening cardiac events later in life. For many others, the inability to get back to normal life can be plaguing, and lead to mental health challenges. Some become so debilitated that they require regular physical therapy to get back to a state of their normal functioning.  

 

Putting Together the Direct Effects on Kids

So, how do we put all of these direct effects on kids’ health together to understand the risk that COVID-19 poses to the health of our young citizens? While many have claimed that the low death rate in children is low, it’s important to note that COVID-19 ranks as the eighth leading cause of death in 5-11 year olds from the beginning of the pandemic to current date. 

 

Indirect Effects of COVID-19 on Kids

While healthy children have fared far better than adults in terms of acute respiratory COVID-19, kids are certainly not unaffected bystanders in this pandemic.

 

How COVID-19 Has Disrupted Education

Most parents will remember March 2020 as the month their child’s school closed down as a way to “flatten the curve”. Our school-aged children did not return to regular in-person education for the rest of the school year. At that time, there were so many unknowns. We didn’t have as much data about the immediate or long-term health effects of COVID-19 on children. And in a time of chaos, lessons learned from prior pandemics (namely prior influenza pandemics) were applied as public health strategies early in the US’ response to COVID-19. 

I am by no means criticizing the March 13, 2020 school closure. But it’s extremely important to note that we know MUCH MORE NOW about how COVID-19 is spread (and how the spread can be prevented) than we did in March 2020. As schools worldwide implemented all the mitigation strategies in schooling environments, we have amassed data on the successes of operating schools in person. But why even take the risk?

 

The Importance of Education in Kids’ Lives

Children are like sponges. They are constantly soaking up their environments and learning, and at a break-neck speed, which varies vastly at different developmental stages. Education is built upon iterative, sequential stages over time. Any parent who has dealt with learning challenges in their own kids can attest to the difficulty of making steady progress if a child misses a foundational concept or subject. To find the optimal learning environment is difficult for every child, as kids have different aptitudes, shortcomings, attention spans and dispositions… and these can vary for each subject that a little one learns! It’s because of all of these idiosyncrasies that I’m constantly amazed by what teachers accomplish in their learning environments. Now I am not an education expert, so I have relied heavily on the expertise of the American Academy of Pediatrics in their assessments and advocacy for children and education during the COVID-19 pandemic. In closely following their publications and policies over the past year, it has become abundantly clear that in-person education is superior to virtual education for the vast majority of children, assuming that the school districts can operate safely with COVID-19 mitigation strategies. What has been observed in areas with extended hiatuses from in-person education?

1. An increasing percentage of children have not achieved their expected developmental milestones
2. Standardized test performance has dropped over time 
3. Children with special needs received zero additional educational attention 
4. Those with low access to the internet have lagged for more than those with reliable internet access 
5. Well being and mental health has plummeted, Cue the next section

 

Socialization Needs of Children

Parents recognize that the development of children is extremely dependent on direct interactions with others. This includes interactions with adults as well as other children. The younger the child, the more vital these interactions with others are. Think of your children and how they respond to being told what to do, compared to learning by the behaviors of others (whether good or bad). Children constantly need to observe others, participate in social exchanges, learn from them, adapt, try tactics out on others, learn, adapt, try, learn adapt and try. This is something that cannot be meaningfully replicated outside of a group environment. If children do not participate in these real world experiments day in and day out, they simply cannot develop the full array of social skills that are expected of them as teenagers and young adults. The bulk of this type of learning occurs at school for kids. This is NOT to say that children who are home-schooled or spend the majority of their time at home CANNOT develop these skills; these skills do however need to be fostered in different ways in these scenarios. 

Many of us parents can personally attest to the behavioral issues observed during the most strict lockdown periods in the pandemic. And not only that, what happened when our kids were allowed to interact with other kids again. It was mind-boggling, to see how quickly children lost track of how to engage and interact with each other.  

The statistics on the impact of the COVID-19 pandemic on the mental health of our youth is frankly staggering. Those of us who work in children’s hospitals have seen firsthand the exponential rise in demand for acute psychiatric care. In 2021, the rates of emergency departments visits for suicide attempts increased 51% in the late winter of 2021 compared to the same time in the year prior. Mental health concerns in children and adults, substance abuse, domestic violence, and child abuse have all soared as the pandemic has trudged along. 

 

How Children Suffer When Caregivers Suffer

Although my kids may not always agree with this statement (depending on how mad they are at me for being too strict), children’s parents and caregivers are unequivocally the most important and stabilizing factor in the life of a growing child. So what happens when their parent or caregiver suffers a physical Illness, like death or disability from COVID? Or a parent’s mental health decompensates due to their own isolation, grief, or lack of mental health care? Such traumatic events may cause “toxic stress” in the life of a child, and the accumulation of these toxic events have been shown to adversely affect the wellbeing and functioning when they become adults. Therefore, as we strive to prevent unnecessary death and disability to the adults in our community, we are fostering the health and wellbeing of their children. 

 

Looking Forward

In the coming months and maybe even years of the COVID-19 pandemic, we need to think critically about how children are affected by the virus itself and how their lives have been dramatically changed by our attempts to control the spread of the virus. Much of the time, it feels like we’re walking a tightrope, trying to find that balance of reasonable risk that is worth all of the benefits. But this incredibly important balance is precisely why so many experts in pediatrics have strongly recommended resuming in-person education as much as possible while using prevention strategies that have been shown to prevent COVID-19 outbreaks in communities and schools. 

In my next blog, I will discuss how we can meet the many needs of our growing little future community members while keeping the virus at bay as much as we can. 

 

Written by:
Rosey Olivero, MD

Co-founder and CSO of Inspired Biometrics

November 11, 2021