What we're learning about how COVID-19 is impacting children

Children and teens seem to be the only bright spot in the COVID-19 pandemic. The first large analysis of pediatric cases in the U.S., released Monday by the CDC, found that children are less likely than adults to become severely ill or wind up in the hospital.

The analysis looked at just over 149,000 cases reported from Feb. 12 through April 2, for which age was known. Children ages 18 and under accounted for 1.7% of the cases. The data was incomplete on many of the cases, but among those with available information, 73% of young patients had fever, cough, or shortness of breath, compared with 93% of adults ages 18–64. Nearly 6% of pediatric patients were hospitalized for COVID-19, compared with 10% among adults, though again, these percentages might be skewed by insufficient data. Hospitalization status was known in less than a third of these pediatric cases.

The findings are remarkably consistent with the experience in China, where patients ages 18 and under account for less than 2% of reported cases. A recent study of 2,143 pediatric patients in China found that almost all recovered without the life-threatening complications that have exploded among a subset of adults.

And a study from Wuhan’s Tongji Hospital offers encouraging news for pregnant women, though it is much too small to be conclusive. Researchers tracked seven women who had COVID-19 late in pregnancy and reported good outcomes both for them and their newborns. The women recovered after treatment with oxygen and antiviral medication. The babies were born by cesarean section.

Still, as data show and heartbreaking news is beginning to tell us, infants, children and adolescents are not immune from the worst effects of the novel coronavirus. Connecticut and Illinois have each announced the death of an infant who tested positive, though in both cases the cause of death is under investigation. Last week the British media carried stories of 13-year old Ismail Mohamed Abdulwahab, who was put on a ventilator at a London hospital and died alone. Family members were not allowed by his side because of the risk of infection

Given the enormous scale of the pandemic in the United States and globally, even a tiny risk of life-threatening complications could translate into a lot of suffering for children and their families, said Dr. Mary T. Caserta, an infectious disease specialist and professor of pediatrics at the University of Rochester Medical Center, in upstate New York. “I believe all pediatricians in the country are thinking about how to prepare for COVID-19,” she said.

Children’s Health Matters spoke with Caserta about how the pandemic is affecting children’s health and changing pediatric protocols. On the day we spoke, Monroe County, where Rochester is located, had confirmed 390 COVID-19 cases, including 10 deaths — all in adults. This is an edited version of the conversation.

Q. Why is COVID-19 generally milder in children?

A. It’s a mystery. There are lots of hypotheses. One is that perhaps the virus doesn’t bind as well to cells in children, or there’s something different about the receptors in children (the proteins on the cell surface that give the virus an entry point). Another theory is that children’s immune response is different than it is in adults. There’s some suggestion that some adults have a significant immune response, which makes the disease worse. Some people are speculating that children often have lots of respiratory viruses in their nose and those might be interfering with this virus.

Q. Do we see the same pattern with other respiratory viruses?

A. With the more well-known respiratory viruses like flu or RSV (respiratory syncytial virus), children suffer a significant burden of disease. Infants and young children have a hospitalization rate from flu that really is surpassed only by people over 65.

Q. What about the pattern with other coronaviruses?

A. Children can acquire the four standard human coronaviruses and thankfully, they're more like colds, the way they are in adults. Coronaviruses like SARS and MERS, which emerged in the recent past, have a similar pattern to what we see now with COVID-19. From SARS there were no fatalities in children, even though the death rate in adults was significant.

Q. Do certain conditions, like asthma, predispose children to serious COVID-19 complications?

A. We don’t have the data to tell us because there are so few deaths reported in children.

Q. What role do children play in spreading the virus?

A. There is one case report of an infant in China who transmitted the virus to her parents. But most of the cases reported so far appear to be children infected from others in family clusters or from exposure to other infected adults. When we have more data from serology and know the number of asymptomatic infections, I think we will be able to determine how much of a role children play in transmission.

Q. What special provisions need to be made for children who are hospitalized with COVID-19? Keeping out family members seems especially tough.

A. I know people are making allowances for children and we do need to think about them differently. I can only tell you what we're doing in our hospital. All children who are hospitalized for any reason are allowed to have one caregiver with them at all times. It’s one person, identified at the beginning of the hospitalization. The caregiver is screened with questions about their own health and temperature screens. The caregiver can order meals from the cafeteria, just as the children order from food services, and they're delivered directly to the family. It minimizes the need to leave the room or to have to go out and mix with other people.

Q. When did this policy begin?

A. It's been going into effect in stages — I’m sorry, it’s so hard to know with time now. It seems like it was weeks ago but it was probably just a few days ago. With time, it has gotten more stringent.

Q. What do you think will be the greatest effects of the pandemic on kids?

A. Certainly where the country comes out on the other side economically could have very big impact on children, especially if they come from families that are struggling. And certainly, the loss of a parent or a loved would be devastating to a child. In terms of school? They’ll get back to learning. All of this is a terrible disruption. But those two impacts — an economic hit and loss of a loved one — pose the greatest threats to children’s security.