COVID-19 guidance for children: severity of disease in children and role of children in spreading infection

Ever since COVID-19 entered global conversation as a serious issue, one concern has stood out amongst all others. How safe are children and the young? The Spanish flu outbreak of 1918 was most deadly for those in their twenties and killed millions of those who had just survived the first of the World Wars.

The data on the COVID-19 pandemic so far is assuring. There is near unanimous agreement that children are not as severely affected as adults. In fact, less than 2% of reported cases in China, Italy and the US have been in people under 18 years of age.

However, the picture becomes murkier beyond this. Researchers are unsure if children are less likely to get infected or to what degree they are contagious. Answers to these questions will help guide policy decisions about reopening schools which have been shut in much of the world in an effort to contain the spread of the virus. Countries like Germany and Denmark have already opened some schools - but with restrictions like physical distancing - and if there is a surge in cases we will know that children are more contagious than we think currently. Many experts have said that it is simply too early to reopen schools since there is not enough data to justify the move.

There are also concerns about virus transmission in utero - meaning from an infected mother to a baby in the womb. Evidence currently suggests that this is not the case as babies born to infected mothers have tested negative; however, it has been recommended that babies are isolated from infected mothers until they recover. At the same time, there has been at least one stillbirth, and cases of premature births. Some infants have been mildly sick while others have required ventilator support; the sample is simply too small and outcomes too varied to say much with certainty.

There also seem to be differences in the onset and symptoms of the disease. According to a study published in Frontiers in Paediatrics, 4 out of 5 COVID-19 children admitted to a hospital for other conditions did not initially present respiratory symptoms - gastrointestinal symptoms were the first signs of infection. While it was a small study, this could mean that children are going undiagnosed since they don’t present classical symptoms as readily.

Here is an examination of the severity, susceptibility and infectiousness of children, updated with the latest studies.

Covid guide: How severe is COVID-19 in children?
Covid guide: How easily can children get COVID-19?
Covid guide: are children silent spreaders of the infection?

Doctors for COVID-19 guidance for children

Covid guide: How severe is COVID-19 in children?

As stated above, COVID-19 does seem to be less deadly for children. However, there have also been cases of children falling severely sick and dying as well.

A study published this month in JAMA Paediatrics looked at 48 children and young adults up to 21 admitted to the ICU in the US. Two of the children died and 18 required ventilator support - two were still on support at the conclusion of the study. Broadly speaking, this report shows that children seem to have better health outcomes when admitted to the ICU compared to adults.

Further, 40 out of the 48 had comorbidities and nearly half had very serious underlying conditions like cerebral palsy or had received tracheostomies. This suggests that, similar to adults, children with underlying conditions are more likely to have the severe form of the disease.

Over the last couple of weeks, there has been a surge in cases similar to Kawasaki disease in children infected with COVID-19. For now, doctors are calling it paediatric multisystem inflammatory syndrome. Symptoms include rash, abdominal pain, fever, and there are blood circulation problems. It appears to be caused by an overactive immune response, and some children have gone into shock caused by low blood pressure and the inability to pump enough blood and nutrients to vital organs. The syndrome appears to be a generalized inflammation response and not just contained to the lungs.

The new syndrome appears to be different from Kawasaki disease (which is also an inflammatory response that causes widespread symptoms) since it seems to affect the heart differently, and is more likely to cause shock.

So far, at least three children have died from the syndrome in New York and one in London. Andrew Cuomo, the governor of New York, said that there at least 50 cases matching this description in the state currently.

Again, this is a very rare situation, and the data on it is limited. Children seem to respond well to anti-inflammatory treatment, and doctors are also treating experimentally with hydroxychloroquine and remdesivir.

Overall, the picture could be worse. While the vast majority of children are not likely to fall severely sick, there is a small subset that does. As to why children are less likely to fall more sick, research is ongoing. It may be that children have fewer active ACE2 receptors in their lungs, which is what the virus latches on to. It may also be that children produce lower levels of cytokines in response to infections - high levels of anti-inflammatory cytokines can cause cytokine storms that have been known to cause lethal consequences in adults.

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Covid guide: How easily can children get COVID-19?

The evidence on this is conflicting. A study published in the Lancet on April 27 based out of Shenzhen, China stated that children under 10 are just as likely to get infected as adults. Since then, other reports have said otherwise. Researchers in Iceland found no infections in 848 children under 10 without symptoms. They did find an infection rate of 1% in ages 10 and older, however. A US analysis found that just 1.7% of 150,000 infected people were below 18. Other studies from South Korea and Italy have also shown lower levels of infection amongst children.

Some researchers argue that these figures are underestimated since children are less likely to get tested because they have milder symptoms. A study by the National Institutes of Health (NIH) that started on 4 May it will follow 2,000 families for 6 months to understand how likely children are to be infected and to what degree can they transmit the disease.

Covid guide: are children silent spreaders of the infection?

Some studies have shown that viral RNA present in the nose and throats of children is similar to that of adults. This would imply a higher viral load, but what that means is contested. So far, it can’t be said with certainty if viral load is correlated with how infectious a person is.

A meta-analysis conducted by the University of Queensland found that children were unlikely to be the first ones to be infected in a household; only 8% of households were those where children were infected first. Similar research by the Dutch National Institute for Public Health and the Environment (RIVM) found that not a single household amongst 54 consisted of a case in which a child was first infected.

Another Australian report observed that out of 850 people who had come in contact with nine COVID-19 positive children, only two were infected.

Detractors of these studies say that the samples are too small to come to a conclusion on the matter. They cite the example of the 6-month-old baby who was asymptomatic but carried viral levels similar to that of adults.

Real-time studies will eliminate sampling biases and give us a better idea of the situation.