In this module, we'll explore the unique characteristics of COVID-19 disease in the pediatric population. It is important to keep in mind that our understanding of COVID in general as well as COVID in children continues to expand. This module contains many reference links, some of which are frequently updated. You will see that some of the studies mentioned contained conflicting information. As our understanding evolves, we hope to have a more clear picture of how COVID affects children. Understandably, the current pandemic has aroused anxiety and fear in many parents. Parents have many questions regarding the safety of returning to daycare or school, and even whether it's safe to go to the playground to play with other children. Epidemiologically, children account for only 1-2 percent of confirmed cases of disease. Despite this, there's evidence that children are more likely to be asymptomatic from infection. The link provides up-to-date information on cases worldwide, including in children from Johns Hopkins. The direct impact of COVID-19 on children is currently small, and the main reason we are keeping children at home is to protect adults. Difficult decisions are being made worldwide about how best to protect children from the direct and indirect consequences of COVID-19. COVID-19 appears to cause fewer symptoms and less severe disease in this age group compared with adults and are associated with much lower case fatality rates. Preliminary evidence suggests that children are just as likely to become infected with SARS-COVID-2, but are less likely to be asymptomatic or develop severe symptoms. The attached link provides a dashboard on the current status of cases in Houston and Harris County. Several studies have looked at the attacked rate in children, as noted in the attached slide. The attack rate is the percentage of the population studied that contracts a disease in an at-risk population. After initial studies in China suggested that the attack rate was the same in children as in adults. Further studies have suggested that the rate is likely much lower, especially in regards to adults over the age of 60. Other studies in Iceland and Italy seem to confirm these findings. A study from Spain also suggests a relatively low infection rate in children as compared to adults. Most spread, especially outside of households, is likely adult-to-adult respiratory spread. Children are more likely to be asymptomatic and when they do have symptoms, they generally have fever, dry cough, and fatigue with some upper respiratory symptoms. Some experience abdominal discomfort, nausea, vomiting, stomach aches, and diarrhea. Most pediatric cases are mild and recovery occurs generally within 1-2 weeks of onset. Infants may be more vulnerable to disease than older children. Children at all ages appear susceptible to COVID-19 and there does not appear to be any significant gender differences. Although clinical manifestation of children's COVID-19 cases are generally less severe than those of adult patients, young children, particularly infants, are vulnerable to infection. Fortunately, hospitalization is relatively rare in children, but it is more common in those with underlying medical conditions, often referred to as those children receiving complex care. The attached link to the CDC website provides weekly updated surveillance updates, including hospitalization rates based on age. A fever and cough remain the most common symptoms among both adults and children when symptoms are present. They are much more likely to occur in adults. In one study, children were found to be less likely to have diarrhea or sore throat. While COVID-19 is more likely to be asymptomatic in children, there is a serious complication that can be seen as a sequelae of the disease. In the United States, this has been referred to as multisystem inflammatory syndrome in children. It is unknown if this syndrome occurs in adults, but it has been seen in some teenagers. It appears to be similar to Kawasaki disease, which is a vasculitis of unknown origin. Indeed, some children with this post viral syndrome fully meet the criteria for Kawasaki disease. Concerning symptoms for children with this syndrome include persistent fever, gastrointestinal symptoms of abdominal pain, vomiting, or diarrhea, difficulty breathing, and any change in their mental status. Diagnostic criteria include age less than 21 years, fever greater than 38 degrees Celsius, which is a 100.4 degrees Fahrenheit for at least 24 hours. Blood work consistent with signs of inflammation such as an elevated C-reactive protein or sed rate, and severe illness requiring hospitalization for involvement of at least two organ systems. In addition, other more likely diagnoses should be ruled out, and there must be a positive test for current or recent infection with a virus that causes COVID-19. There is some evidence that children may be less likely than adults to actually acquire the infection. Most childhood cases emerge from family clusters with most having epidemiological links to infected adults. One study out of Germany suggested that viral loads in children may be similar to that of adults, but it is unclear if this correlates well to ability to spread the infection. There's also evidence of prolonged shedding of the virus which certainly has implications for spread. Adults can help children prevent spreading the virus through frequent hand washing, making sure children cover their coughs and avoid touching their faces, cleaning and disinfecting high touch surface areas, avoiding crowds and respecting safe-at-home recommendations. In addition, it is important that children stay at home when ill especially avoiding those who may be at high risk for disease. The pandemic has affected almost every aspect of life and these changes, as well as a disruption to school and daycare and usual routines, can be overwhelming and frightening for children. In talking to children about the pandemic, it is important to provide reassurance, letting them know that doctors and scientists around the world are working hard every day in an effort to keep everyone safe. It is important to give children a sense of control by helping them understand the way in which they can maintain some sense of routine through homework and chores, as well as ways in which they can help prevent spread. Parents must be vigilant in watching for signs of stress, anxiety and depression, seeking help from pediatricians and behavioral health professionals when needed. It is important for parents to monitor the media their children are exposed to, in order to allay their fears and correct any misinformation. Parents must model good behavior and be empathetic toward those who are ill. There has been a disruption of routine healthcare and vaccination for other preventable diseases, so the AAP has started a campaign to remind parents about these important preventative visits. Your personal pediatrician is likely a great source of information as they understand your particular family circumstances. There are also new books aimed at children that can be shared to provide accurate information. The toll of the Corona virus pandemic extends beyond the illness itself. There's real harm due to social isolation, lack of protections provided by school attendance, increased anxiety and a dropped in the ability of health services, education and social services. This is particularly true for the most vulnerable children. In areas, there has been a noted increase in the number of suspected child abuse cases. The resources many at-risk parents rely on, such as extended family, childcare in schools, religious groups and other community organizations are no longer available in many areas. When there is household dysfunction, such as domestic violence, parental substance abuse, or a mental disorder, the risk of child abuse goes up and it's reasonable to believe that all of these things will increase during the pandemic. Despite some evidence regarding children as super-spreaders with prolonged viral shedding, there are other studies that suggest this may not be the case due to their milder symptomatology. There had been few recorded cases of adults catching the disease from children and there had been no apparent outbreaks in schools, although that could be due to children showing few symptoms. Despite this, teachers may be at risk from other teachers, as is the case between workers and other jobs. As mentioned, one of the consequences of the pandemic is the interruption of routine child healthcare and immunizations. Vaccinations have been disrupted for several reasons. Some parents are no longer taking children to clinics because of movement restrictions imposed to slow the spread of the virus or because they are scared about the risks of exposure to the virus. Health care workers who provide vaccinations have also been diverted to help with the response to the pandemic. As might be expected, our most vulnerable children are likely at the highest risk. As we have seen in recent years with outbreaks of measles among the non-vaccinated, these infections need only a small window of opportunity to recur. The American Academy of Pediatrics is greatly concerned about the rates of immunization falling below that which provide herd immunity and is working to get the message out with their hashtag, #CallYourPediatrician campaign. Understandably, the current pandemic has aroused anxiety and fear among many parents. Parents and caregivers should look to their local government school districts for information regarding the safe return to school. The CDC has organized recommendations depending on the local community spread. These range from safe return guidelines to school re-closure. Social distancing is the essential key to controlling the spread of the virus. There are several recommendations, including those listed here, to limit contagion as schools reopen. Again, do not forget about the importance of routine vaccination. With precautions in place, it is felt to be safe to return to physician offices and seek medical care when needed.
