What we know about COVID-19 in children

A new viewpoint article published in the journal JAMA Pediatrics in April 2020 discusses the manifestation and management of the novel coronavirus disease devastating several countries.

First described in Wuhan, China, as pneumonia of unknown origin, it has rapidly moved over the world, currently infecting almost 210 countries and territories, with a caseload of well over 1.41 million.

What is a coronavirus?

Coronaviruses produce many different illnesses, from minor colds to severe or fatal pneumonia. Three major virus strains have emerged over the past two decades, the one which caused severe acute respiratory syndrome (SARS) in China, 2002; the agent of the Middle East respiratory syndrome (MERS) in the region of Arabia in 2012; and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19 disease.

Novel Coronavirus SARS-CoV-2 This scanning electron microscope image shows SARS-CoV-2 (round gold objects) emerging from the surface of cells cultured in the lab. SARS-CoV-2, also known as 2019-nCoV, is the virus that causes COVID-19. The virus shown was isolated from a patient in the U.S. Credit: NIAID-RML

In over 80% of cases, based on Chinese statistics, the disease is mild. But 14% of patients have severe illnesses such as trouble with breathing and respiratory failure. Older people, as well as those with underlying illnesses, are at higher risk for severe sequelae.

The disease spreads by respiratory droplets emitted via coughing or sneezing, to within 6 feet. Other types of transmission may also occur. Supportive care is required, with no specific therapeutic drug having been approved so far. Vaccine development is still ongoing.

COVID-19 and children

In all known influenza epidemics, children are seen to be at higher risk for serious complications. However, they have so far been spared in the ongoing pandemic of COVID-19.

Chinese statistics from 72,000 cases shows 1.2% of cases occurred among children aged 1 to 19 years, and only 0.9% when only those below the age of 10 were considered. Only one person died in this age group.

In another study, however, involving over 2000 children with confirmed or suspected COVID-19 in China, the researchers found that 10.6% of infants would develop severe disease, compared with 4% of children aged 11 to 15 years and 3% of those aged 16 and above.

How does COVID-19 appear in children?

In children, COVID-19 appears to have the same clinical features as in adults. Many are asymptomatic, while others presented with fever, fatigue, dry cough, and shortness of breath. Few had gut symptoms.

Only a few pregnant women who contracted the virus were identified, making it difficult to assess the occurrence of intrauterine transmission. Breast milk samples have so far tested negative for the SARS-CoV-2 virus.

The researchers say that even though few children got the illness and even fewer died, “there are reasons to remain vigilant about infection in children.”

The reasons for the low incidence among pediatric patients include less exposure to the virus, immunity to other coronaviruses, or a smaller chance of developing symptomatic illness even when infected. Asymptomatic infected children could spread the virus to other adults.

In the US, no children below the age of 19 have been admitted to the intensive care unit, nor have any deaths from COVID-19 been reported up to March 16, 2020, say the authors.

However, children with asthma or other underlying illnesses which affect respiratory function could have serious illnesses, compared to their healthy peers.

What can pediatricians do to prepare?

The authors suggest that pediatric care clinics take steps to prepare themselves to deal with a rising load of COVID-19. For one, they should have separate isolation spaces for children who might have COVID-19, so that children who are in the waiting room but are not sick are not exposed to the virus. This applies especially to children with special needs.

Where community transmission is common, only urgent visits by healthy children should be allowed, and other elective or minor procedures could be postponed.

Vaccination should be continued and preventive visits for newborn babies and infants. This kind of action will require diligent sorting of requests and indications for visits by phone calls, and offering more telehealth services.

Finally, pediatric care providers will find it hard to differentiate children who have COVID-19 from others unless testing becomes more widely available.

Instead, communities in which the virus is rife should take measures to limit exposure of the uninfected, including cancellation of school terms, avoiding all mass gatherings, and closing public places.

Some of the fallout of these measures will affect the pediatric population. For instance, children who depend on the school lunches for a significant part of their daily food will have to be catered for in different ways if schools are shut.

Families who depend on schools to take care of children while parents work could also experience severe disruption of routines in this situation, and stress management services should be advocated for.

Such measures are best spoken for by pediatricians due to their familiarity with the population group to which such actions cater.

What is the take-home?

While COVID-19 is still spreading rapidly, with fewer effects on children than on adults, yet the long-term effects due to preventive and public health measures may affect children still more in the long term.

Secondly, the effects on children with special care needs due to underlying illness are still unclear. Thus pediatricians, educators, and other leaders of the community must foster interventions that will slow the spread of the illness, cut the rates of serious disease and death, and minimize adverse effects of these measures on children.

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