COVID-19 and Children – Six Months In

Dr. Rick Place is Medical Director of the Pediatric Emergency Department at Inova Children’s Hospital (at Inova Fairfax Medical Campus in Falls Church, VA). Dr. Place is a board certified physician in both Emergency Medicine and Pediatrics.

Although it feels like much longer, it has only been six months since the novel coronavirus SARS-CoV-2 was first identified in Wuhan, China. Since then, COVID-19 (the name for the medical condition caused by the coronavirus) has dominated our news feeds, our social media, our work and social lives, our financial lives, and for a number of us, our health. Here is a summary of what we have learned about this virus as relates to children – with the caveat that it may be dated in a month.

How contagious is SARS-CoV-2?

Without social distancing and universal masking, every person with COVID-19 will infect approximately two to three other people. This is more than swine flu and more than Ebola, but less than measles.

A little back-of-the-napkin math: Starting with a single infection, if every person with COVID-19 infected two other people within a week, there would be 67 million infections at the six-month mark. Fortunately, models show that high acceptance of public masking and social distancing can reduce the transmission rate to less than 1.0 and strangle the spread of coronavirus. For real.

Do kids get COVID-19?

Yes. But they do not seem to be as vulnerable to getting infected or getting sick with infection as adults. Children constitute approximately 22 percent of the American population, and in April, only 2 percent of COVID-19 infections were in children. It was unclear whether they are inherently protected from getting COVID-19 or just not yet exposed. Remember, schools closed early in the pandemic.

However, time has shown that children do get infected in substantial numbers and can easily pass coronavirus to each other and within their families. As the social distancing measures of the spring have loosened, and as kids have gathered in larger groups, we have learned there is significantly more potential for infection than we realized. Consider the mass infection at the sleep-away camp in Georgia this summer.

Even if there is less risk, less risk is not no risk. And less spread is not no spread, especially if the spread is to vulnerable school teachers and grandparents.

Is COVID-19 dangerous?

The vast majority of children (of all ages) just have fever and flu-like symptoms and get better in a few days. Just like influenza, infants and children can get quite ill with COVID-19 and may require hospitalization. Every year, a few children with the “normal” flu die. The same will be said of COVID-19. We have already had three teenagers this year at Inova who were on a heart bypass machine necessitated by COVID – and fortunately, they all survived.

The major risk is passing it on to their more vulnerable adult family members. Children with COVID-19 can indirectly and unknowingly cause severe harm to others when they do not mean to.

What are the symptoms of COVID-19 in children?

They seem to be a little less specific that in adults, who predominantly present with fever, muscle aches and shortness of breath. COVID-19 can present this way in children, particularly teens, but many children just present with fever and decreased appetite. They may have coughing without fever, sometimes congestion, often with vomiting and diarrhea. They may not have fever – or even be asymptomatic – and only discovered to have COVID-19 when tested for other reasons, such as preparing for surgery.

In other words, while most children will present with a flu-like illness that looks just like any other virus, the range of symptoms can be quite wide.

What is the treatment if my child gets COVID-19?

Currently, there is no recommended treatment for coronavirus infection in children who are not sick enough to be in the hospital. Ibuprofen (Motrin) and acetaminophen (Tylenol) are good for typical symptoms.

More important than a specific medicine for COVID-19 is a good, watchful eye on your part. Bring them to the doctor (or the emergency room) if they seem to progress from “feeling bad” to looking lethargic or short of breath.

If there is no treatment, then why bother to test for COVID-19?

For children who are not sick enough to be in the hospital, the main reason to diagnose COVID-19 is that the knowledge allows you to rigidly isolate your child to prevent your child from spreading this illness to others and to quarantine family members.

The CDC currently recommends people (adults and children) with COVID-19 to maintain strict home isolation for 10 days from the onset of symptoms AND until they are at least one day fever-free. (Isolation means to separate sick people from well people.)

For those family members and friends exposed to your child, the CDC recommends 14 days of quarantine (which means separating exposed people from well people.)

Why is quarantine in well people longer than isolation in sick people? Because it may take up to 14 days for some people to show signs of COVID-19 if they are infected. Once infected, people become noninfectious within 10 days.

What is MIS-C (multisystem inflammatory syndrome – COVID-19) that we have been hearing about?

Multisystem inflammatory syndrome (MIS-C) is a post-infectious reaction to the virus, usually occurring two to four weeks after the coronavirus infection has come and gone. Even after the infection has been cleared, some patients will have an unexpected and unhelpful immune reaction that damages the body – collateral damage, if you will, in the fight against the virus.

Children may present with just (persistent) fever but very usually have abdominal pain, vomiting or diarrhea, or other nonspecific symptoms. For some children, it may only cause prolonged fever, for some it may look like Kawasaki disease, and sometimes children present in shock. This condition is usually diagnosed with lab testing to look for severe inflammation and damage to the body’s organs in children who have had or have been exposed to COVID-19 (although the initial infection in some children may be asymptomatic).

However, while this condition has been widely reported across the globe, what is not well emphasized is that MIS-C is extremely uncommon. However, when present, MIS-C does require hospitalization and aggressive medical care.

When do I need to worry about MIS-C?

These children are sick. They look and act very unwell, with fever, sometimes red eyes and lips, a rash, and often abdominal pain. There can also be associated cough, shortness of breath, weakness or headache.

It is still worth remembering that most children with fever do NOT have MIS-C and do NOT need lab testing.

What are the most important things to remember?

• While children can easily get coronavirus, the vast majority tolerate it well, like any other virus. The main danger is spreading it to more vulnerable adults.
• Some children do get sick with COVID-19 and need to be in the hospital. That is why ANY sick child should be seen in the emergency room for an evaluation.
• Understanding proper isolation and quarantine are very important if your child is diagnosed with COVID-19.
• MIS-C is a serious condition that happens two to four weeks after a coronavirus infection. It is extremely rare but is a well-recognized condition that would be diagnosed by your pediatrician or pediatric emergency doctor.

Finally – I will say it again – until a vaccine arrives, proper masking, hand washing and social distancing are the best weapons in our fight again this virus. Masking saves lives. For more information on helping your kids practice these measures, please visit inovachildrens.org/covid19.