6 months in and what have we learned about Covid-19 and children? Are their symptoms different? Are children as likely to get infected as older people and if infected, can they shed the virus and make others sick? And how likely are children to get a severe illness ? Stay tuned for this “don’t miss” episode of Portable Practical Pediatrics to find out the answers to these questions
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The Pandemic So Far for Children in the U.S.
Six months into the U.S. phase of the pandemic and there are so many questions regarding Covid-19 as it relates to children. Research into vaccines and therapies for adults have been the focus of the daily headlines probably because so few children have died of the direct infection. Clearly, age is the biggest risk factor for severe disease. But research is starting to roll in about the roll children play in this pandemic. Just because research in children has been sparse to date, doesn’t mean that this age group is unaffected by SARS-CoV-2. In the following pedcast, I am going to lay out some of the key questions researchers are asking and when possible, give you their answers as we know them today. But remember, I am recording this podcast in September 2020 and things can change so tune in regularly for updates. I’ll do my best to make you the best informed parent in the room.
The Questions Needing Answers
Question 1. Can children get infected and if so, do they shed virus that can make others ill? Well, we don’t have to dig too hard into the literature or news to find an answer to the first part of this question. We have all seen universities closing down rapidly after just a few weeks of opening due to clusters of Covid-19 among their students and staff, The University of North Carolina in my home state, being one of the first in the U.S.. Similar outbreaks have been seen now in many other universities and even high schools, the most famous of which was in Israel in June 2020 where one ill student seems to have started a cluster that rapidly spread through the school to other students and faculty. And it is not hard to understand how this happens since we now know that a person infected with SARS-CoV-2 sheds the virus the day before they get ill, during their illness, and a few weeks after recovery similar to most viral infections. Additionally, we now know that after age two years, the young preschool and elementary aged children have fewer symptoms that indicate illness. This fact makes identifying Covid-19 in children very difficult. More on that in a minute. And finally, as far as shedding of the virus, the news here is not good. Recent studies have shown that even though young children are unlikely to get seriously ill from SARS-CoV-2, they can shed and possibly pass on 10-100X the amount of virus in their nasal secretions than adults with severe illness do! Yong children with Covid-19 may indeed be the generators of community spread like they are for so many other respiratory viruses. Some epidemiologists even go as far as to surmise that the biggest contributor to flattening the curve that we saw last spring didn’t come from our social distancing, but rather from the closure of schools.
Question 2. How likely are children to get a severe case of Covid-19 that leads to death? This is an interesting one. I think the Chinese answered this question for us before Covid-19 even reached our shores- children are much much much less likely to get severe illness than adults. Thank goodness. Severe infections in children are possible but not likely. If infected, children usually get mild illness thank goodness. Of those children who do go onto hospitalization, as you might expect, a disproportionate number have underlying other health problems like obesity, underlying lung disease, or a history of prematurity. For reasons that are not fully understood however, children of certain ethnic groups have a higher chance of severe illness than others. According to the CDC, African-American and Hispanic children are at most risk for severe illness. More on that topic when I interview integrative pediatrician, Dr. Chris Magryta on an upcoming podcast. I am sure you will find what he says fascinating and informative.
Question 3. Are children drivers of community spread with SARS-CoV-2 like they are with influenza? In answering question number one, I told you that children do indeed shed a lot of virus from their noses when infected with SARS-CoV-2 just like they do with other viruses making it possible that they may indeed be the generators of community spread. Some epidemiologists even go as far as to surmise that the biggest contributor to flattening the curve that we saw last spring didn’t come from social distancing, but rather from the closure of schools. Common sense would tell us that shedding virus is synonymous with spreading illness and being infectious but we are waiting for definitive evidence on this point before coming to final conclusions. Contact tracing has determined that adult to child spread is common but not the other way around for some reason. Personally, I believe that adult to child spread happens often but is often not recognized since the illness in the child is so mild that testing is not indicated.
Question 4. Do children have different symptoms with Covid-19 than do adults? Here is where things that we are learning are getting interesting. American and British public health experts have created a Covid Symptom app that anyone can download and help the world answer this and other questions swirling around Covid-19. To date, they have enrolled 300,000 children whose parents report their children’s symptoms when infected with Covid-19. Here is what they have found- children have some overlap of symptoms with adults sufferers of Covid-19 but really act more like they have strep throat than a novel infection that has jumped from bats to humans just a few months ago. The most common symptoms children get with Covid-19 are headache, fatigue, sore throat, fever, and loss of appetite. Notice that persistent cough, loss of smell, and shortness of breath are absent from the list! If we wait for these symptoms to test children with fever, we will miss many if not most children who are infected. Another thing they have found in this study is that many children have skin rashes as part of their Covid-19 illnesses, sometimes as their first and only symptom!
Ok, let’s summarize things as we know them today. Yes, children get infected with SARS-Cov-2 and yes it is likely but not proven that they can make others sick. The good news, if there is such a thing with the Covid-19 pandemic, is that children over two years of age are extremely unlikely to have a severe illness with SARS-CoV-2 like adults sometimes get. There are certain groups of children who are more likely to be hospitalized or even die, but even among these sub-groups of children, severe illness is rare. As far as the question of children being a reservoir of infection for the rest of the community, time will tell and I think we will know the answer to that question by Thanksgiving after the children have been back in school for a few months. And finally, pediatric Covid-19 is turning out to look a little different than adult Covid-19 illness. Cough, shortness of breath, and loss of smell are not common symptoms but rather the big five for children are headache, fever, fatigue, sore throat, and loss of appetite.
As always, thanks for joining me today. If you think the information you get on Portable Practical Pediatrics is valuable, please take a moment to rate our podcast on Apple Podcasts or wherever you get your podcasts. If you hear your review read on a future episode, contact me and I have an autographed Doc Smo book, tee shirt, or a Doc Smo pearl refrigerator magnet I will send you. This is Dr. Paul Smolen, your pedcast host, hoping to keep your thinking straight, by keeping you up-to-date. Until next time.
Many thanks to Drs. Monica Miller and Charlotte Rouchouze for their help in the preparation of this pedcast.