Let’s Not Kid Ourselves: Children Are Not Unaffected by COVID-19

The emerging evidence on the impact of COVID-19 on children suggests that they are probably as likely as adults to get infected, but are more likely to be asymptomatic or to present with mild symptoms.1

While children appear to be at considerably less risk than adults, the risks to children are nonzero, as children may get severe disease and may require hospitalisation.

A widely circulated video from Iran showed young girls in hospital who appeared to be having serious breathing difficulties, which was attributed by those posting the video to COVID-19. Their treatment may well have been being hampered by the apparent lack of supplemental oxygen. Of course, as the pandemic spreads, we are likely to see medical systems being increasingly overwhelmed.

Another pair of videos show an Iranian child, whose family had all died of the virus and was selling vegetables on the street in Iraq, collapsed on the street, according to the posters, suffering from coronavirus.

As of 14 March 2020, Iran was reporting a total of 12,729 confirmed cases across the country, a number that is believed to be a gross underreporting of the actual number of cases.2 Taking a rough and ready average of seven studies conducted in late February and early March 2020, Graeme Wood, a staff writer at the Atlantic suggested that the true number may be closer to two million cases, and there is little indication that the number of cases in the country has peaked.3 If indeed there are two million plus cases in Iran, even where children have a very low chance of developing severe disease, very sadly, some clearly will.

Isolated cases of children with infection in Europe and North America are beginning to emerge as well although typically these have been less serious cases.4 5 6 7

Update from 31 March 2020. 

More reliable data emerging from Europe shows that children are indeed dying from COVID-19, or complications relating to COVID-19.

Data from China and Italy

Chinese and Italian data tell us that a lower proportion of children are presenting with the disease, and that the case fatality rate among children is also lower.

In the early data from China, as of 11 February 2020, there had not been any deaths among children aged 0-9 out of 416 confirmed cases; and, among 10-19-year-olds, out of 549 cases, there had been one death.8

Similarly, as of 12 March in cases in Italy, diagnosed by regional reference laboratories, there had been no deaths among the 630 infected persons aged 0-19, although it wasn’t indicated in this source what percentage were in serious or critical condition. Neither is it clear at this stage what the risk of lasting or recurrent health problems for children with COVID-19 is likely to be.9

Age Cases % of all cases Deaths % of all deaths Death rate Population Infected ratio
0-9 63 0.5 0 0 0 4994995 1:79285
10-19 118 0.9 0 0 0 5733448 1:48588
20-29 511 3.7 0 0 0 6103436 1:11944
30-39 819 5.9 1 0.1 0.1 6998434 1:8545
40-49 1523 11 1 0.1 0.1 9022004 1:5923
50-59 2480 17.9 14 1.7 0.6 9567192 1:3857
60-69 2421 17.4 65 8.1 2.7 7484862 1:3091
70-79 2849 20.5 274 34.1 9.6 6028908 1:2116
80-89 2138 15.4 355 44.2 16.6 3699654 1:1730
≥90 395 2.8 75 9.3 19 828895 1:2098
Not noted 565 4.1 18 2.2 3.2
Totals 13882 803 5.8 60461828 1:4355

These data are largely par for the course for a coronavirus. The Director of the National Institute of Allergy and Infectious Diseases in the United States, Dr. Anthony Fauci, together with coauthors, Dr. Catharine Paules and Dr. Hilary Marston wrote that, in the case of SARS, there were higher fatality rates among older patients and patients with relevant preexisting conditions. They noted that,  

“Common symptoms of SARS included fever, cough, dyspnea, and occasionally watery diarrhea. Of infected patients, 20% to 30% required mechanical ventilation and 10% died, with higher fatality rates in older patients and those with medical comorbidities.”10

They also highlighted that four “HCoVs (HCoV 229E, NL63, OC43, and HKU1) are endemic globally and account for 10% to 30% of upper respiratory tract infections in adults.”11

Research on Children’s Outcomes

Studies from across Asia have reached similar conclusions, although it should be noted that with relatively few cases, it may be hard to extrapolate the likelihood of serious illness in the broader population.

The authors of a study in Singapore found that symptomatic infections in children were rare, and “in the 3 confirmed cases who were very young (aged 6 months, 1 year, and 2 years), the symptoms were very mild.”12

In a Chinese study of nine infants identified between 8 December 2019 and 6 February 2020, four developed a fever, two had mild upper respiratory tract symptoms, one had no symptoms, and information on two of the children’s symptoms was unavailable. According to the authors, “None of the 9 infants required intensive care or mechanical ventilation or had any severe complications.” 13

In a similar study out of China, the authors found seven children presented with a fever, five with coughing, four with sore throat, two each with nasal congestion and rhinorrhoea, and three with diarrhoea. One child had no symptoms. “None of the patients had other symptoms commonly seen in adult patients such as lethargy, dyspnea, muscle ache, headache, nausea and vomiting and disorientation. In fact, none of them sought medical care; they were all identified and diagnosed because of their exposure history.”14 Looking at cases where families had possible exposure to SARS-nCoV-2, the authors found that adults were more likely to be infected than children. “By 20 February 2020, “a total of 745 children and 3,174 adults, most of whom had either close contact with diagnosed patients or had members of the family reporting familial outbreaks in the previous 2 weeks, were screened by nasopharyngeal swab real-time PCR with reverse transcription (RT–PCR) for SARS-CoV-2 infection. Overall, 10 children (1.3%) and 111 adults (3.5%) tested positive. The 2.7-fold difference between children and adults is statistically significant (P = 0.002).15

In another study of 26 children, a range of symptoms including cough, rhinorrhoea, diarrhoea, vomiting, lymphocytopenia, increases in alanine transaminase or transaminase, and unilateral pneumonia were noted. Nine patients had no obvious clinical symptoms. There were no occurrences of serious complications, such as acute respiratory syndrome and acute lung injury.16

More recent studies, however, appear to be pointing to somewhat greater risks to children. A preprint published on medRxiv found that children were as likely as adults to be infected:

The household secondary attack rate was 15%, and children were as likely to be infected as adults… Notably, the rate of infection in children under 10 (7.4%) was similar to the population average (7.9%).

Analysis of how cases are detected, and use of data on individuals exposed but not infected, allow us to show that infection rates in young children are no lower than the population average (even if rates of clinical disease are).17

Also, in another recent preprint by Hui Yi et al, out of 105 pediatric cases studied, eight were found to be critically ill. 18

In particular, there is concern about newborn children and children in their first year. Jianhui Wang and his fellow authors, writing in the Lancet explained that neonates are “thought to be susceptible to the virus because their immune system is not well developed”, and pointed to “temperature instability, hypoactivity or poor feeding, or tachypnoea” as among the clinical symptoms of SARS-nCoV-2 in infants.19

Understandably, with contradictory data and a still-developing understanding of the disease, scientists are reluctant to make definite claims about the risk to children at this stage. Dr. Marc Lipsitch is among those expressing caution about COVID-19 in children. “We just don’t understand whether children are getting infected at low rates or just not showing very strong symptoms. So I don’t want to make assumptions about children until we know more.”20

Explanations

One explanation for children’s mostly positive outcomes from coronavirus infection is that their body is shielded from cytokine storms when the virus triggers an immune response. Dr. Akiko Iwasaki of Yale University, speaking to the New Scientist, said, “That doesn’t explain why children’s immune systems react differently to coronaviruses compared with flu. It might be due to differences in the type of cytokine response produced against each virus”, while Prof. Wendy Barclay explained that existing antibodies in adults may do more harm than good in the event of an infection.21

Children show a similar, but less marked, response to influenza. There was a 0.002% mortality rate for children aged 5-17, while adults aged 18-49 had a mortality rate of 0.02%, during the 2018-19 flu season in the United States.22

Responses

Given the low but still nonzero risk factors involved with cases of COVID-19 in children, sensible precautions are the order of the day.

As of 13 March 2020, 61 countries had mandated school closures, with 39 closing schools nationwide while 22 announced regional, localised or partial school closures.23

The US Centres for Disease Control and Prevention has pointed to a lack of information on whether children with “underlying medical conditions and special healthcare needs” are at particular risk.24

Drs. Thompson and Rasmussen, writing in JAMA Pediatrics recommend stocking up on at least a two-week supply of food, water and necessities such as diapers, in addition to making sure that families have refills of prescription medications and special equipment, as well as a supply of fever reducers and oral rehydration solutions.25

They also stress the importance of the following:

  • Good handwashing technique;
  • Regular household cleaning;
  • Coughing into an arm or elbow;
  • Staying away from people who are sick;
  • Keeping sick kids at home, i.e. contacting a doctor for advice, rather than going into hospital; and,
  • Following guidance from the US CDC.26

UNICEF meanwhile provides the following handwashing advice:

  • Step 1: Wet hands with running water
  • Step 2: Apply enough soap to cover wet hands
  • Step 3: Scrub all surfaces of the hands – including back of hands, between fingers and under nails – for at least 20 seconds.
  • Step 4: Rinse thoroughly with running water
  • Step 5: Dry hands with a clean cloth or single-use towel27

Or, in kidspeak, washy, washy, clean, scrub, scrub!

Picture by Chris Gonzalez via Pexels.

Footnotes

  1. According to the European CDC, “Currently available information indicates that children are as likely to be infected as adults, however they experience mild clinical manifestations. About 2.4% of the total reported cases in China (as of 20 February 2020) were individuals under 19 years of age. A very small proportion of those aged under 19 years have developed severe (2.5%) or critical disease (0.2%). // Estimates of all of the above parameters are likely to be revised and refined as more information becomes available. https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf
  2. https://www.worldometers.info/coronavirus/
  3. https://www.theatlantic.com/ideas/archive/2020/03/irans-coronavirus-problem-lot-worse-it-seems/607663/
  4. https://milano.fanpage.it/coronavirus-lospedale-di-bergamo-bambino-di-un-anno-in-terapia-intensiva-in-prognosi-riservata/
  5. https://abc7.com/health/8-new-covid-19-cases-in-la-county-3-new-in-oc/6000233/
  6. https://www.wz.de/panorama/zweijaehriges-kind-wegen-coronainfektion-in-potsdamer-krankenhaus_aid-49498035
  7. https://www.businessinsider.com/newborn-baby-tests-positive-for-coronavirus-in-london-world-youngest-2020-3?r=US&IR=T
  8. http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51
  9. https://www.epicentro.iss.it/coronavirus/bollettino/Bollettino-sorveglianza-integrata-COVID-19_12-marzo-2020.pdf
  10. https://jamanetwork.com/journals/jama/fullarticle/2759815
  11. ibid
  12. https://jamanetwork.com/journals/jama/fullarticle/2761890
  13. https://jamanetwork.com/journals/jama/fullarticle/2761659
  14. https://www.nature.com/articles/s41591-020-0817-4
  15. ibid
  16. https://www.medrxiv.org/content/10.1101/2020.03.08.20029710v1.full.pdf
  17. https://www.medrxiv.org/content/10.1101/2020.03.03.20028423v1.article-info
  18. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30040-7/fulltext
  19. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30040-7/fulltext
  20. https://news.harvard.edu/gazette/story/2020/02/key-coronavirus-question-how-are-children-affected/
  21. https://www.newscientist.com/article/2237259-why-dont-children-seem-to-get-very-ill-from-the-coronavirus/
  22. https://time.com/5774516/coronavirus-kids/
  23. https://en.unesco.org/themes/education-emergencies/coronavirus-school-closures
  24. https://www.cdc.gov/coronavirus/2019-ncov/prepare/children-faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fchildren-faq.html
  25. https://jamanetwork.com/journals/jamapediatrics/fullarticle/2763176
  26.  ibid
  27.   https://www.unicef.org/stories/novel-coronavirus-outbreak-what-parents-should-know
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