Pediatric COVID

Through the COVID-19 fog, I’ve gotten to know Dr Kelly Fradin, who’s a pediatrician and mom in NYC. I’ve found her a helpful voice of sanity in parenting and pediatric advice (she’s on Instagram at @adviceigivemyfriends). She wrote a book (seriously, DURING THE PANDEMIC SHE WROTE A WHOLE BOOK) for parents which I highly recommend, and not only because it references my newsletter. You can find it here: Parenting in a Pandemic: How to help your family through COVID-19 or in audiobook here. She sent me the opinion post below, on how to think through some of the scary headlines around long term impacts of COVID on kids. I found it helpful in my own thinking and thought many of you might, also. These are hard issues to think and talk about, and we really do not have any answers. But perspective is important, and I value hers. So here you go! Recently we’ve seen increases in documented cases of coronavirus in children. This surge represents both increased testing of children and increased cases of coronavirus nationally. We’re focused as a nation on the safety of our children and rightly so. Parents are really scared and confused. I hear from my friends, “I was planning to send my kids back to school and then I heard there may be a risk of long-term neurologic problems.” Articles suggesting many children will have chronic problems with their physical health secondary to the direct effects of COVID-19 border on fear-mongering. As a pediatrician, I am not worried about the direct long-term effects of coronavirus for children. Before diving into why, I want to state my goal in reassuring you is not to diminish the true urgency of containing coronavirus. Nearly 170,000 people have died of coronavirus in the United States. While most of these are adults, 105 children have died. Masking, social distancing, and taking precautions to limit the spread of coronavirus are essential to protect our families and our larger community. But it pains me to hear already over-stretched and over-stressed parents panicked about something that I do not consider a real threat. So I want to discuss long-term problems following coronavirus. Several studies have been cited incorrectly to support these concerns. The Morbidity and Mortality Weekly report from the CDC published the results of a telephone survey that showed 20% of young adults experienced fatigue, cough, congestion and other symptoms 2-3 weeks after testing positive for coronavirus. What’s not emphasized is the likelihood that some of the individuals feeling better may have not elected to complete the survey so individuals with longer courses of symptoms may have been oversampled. Also, this finding is in the range of what we see following many other respiratory infections where symptoms like cough and fatigue can persist in 11-25% of adults for 3-8 weeks. Similarly a study in Italy found that 87% of adults had persistent COVID-19 symptoms two weeks following discharge from the hospital. Another study highlighted that 55% of adults hospitalized for more than two weeks for coronavirus experienced neurologic problems even 3 months after infection. These articles highlight real and significant concerns for adults, particularly those unlucky enough to have severe coronavirus requiring hospitalization. A two week hospitalization for any reason reflects a truly major medical illness and will require substantial recovery. We track hospitalizations because they are undesirable outcomes and this further describes what we already know. We shouldn’t discount individual experiences. The research and discussions of long-term problems following coronavirus are important because doctors have to meet the needs of these people as they recover. But these studies don’t change the fact that most children who catch coronavirus are asymptomatic and do quite well. COVID-19 is new. We do not have long term follow up data to guide us, but we do have some clues. The CovKids Project estimates that 2.6 million children have already had coronavirus in the US alone. Internationally it’s another order of magnitude. Enough children have had COVID-19 for long enough that we have been able to identify the multi-system inflammatory syndrome (MIS-C) which is estimated to affect as many as 3 out of 10,000 children after infection. So certainly we have not detected every possible issue, and we’ll have to continue studying children who present with unexpected issues such as those described by CNN. But it’s unlikely that we haven’t noticed a common problem. Most viral complications begin soon after infection so we would have detected surges in most complications by now. We know that almost all viruses have rare complications, every year people suffer from Guillain Barré Syndrome, Kawasaki Disease, transverse myelitis, myalgic encephalitis / chronic fatigue syndrome and other illnesses. Most parents haven’t heard of these terrible complications for a reason - they are extraordinarily rare. Coronavirus has shown a propensity to cause vascular inflammation and heart damage in adults with severe infection requiring hospitalization, but we haven’t seen this in other groups and it seems unlikely that mild cases of coronavirus have any long-term heart issues. The heart damage induced by MIS-C has so far appeared to respond well to treatment. Early in the pandemic, physicians in China used CT scans of the lungs to make a diagnosis of coronavirus. These showed some children with mild disease had changes in the lungs. CT scan is very sensitive to detect lung problems, frequently a child who has abdominal CT has unrelated issues noted in the bottom of the lungs. We haven’t yet heard whether these changes persist, but respiratory syncytial virus (RSV), a common respiratory infection in children, is known to cause damage to the lungs when children have it at a young age. Having RSV before age 2 can increase the risk of reactive airways or asthma that requires treatment. However we do see that as children’s lungs continue to grow until age 8, this damage is almost always outgrown. Could coronavirus cause something similar? Yes, but we have no reason to think that it would be more serious. So what do I worry about with our children and coronavirus - mental health. Loneliness, screens, and disruption of our lives can all increase the risk of significant anxiety and depression. Parents who are stressed in every way may not have the bandwidth to take on the role of child therapist in addition to their other responsibilities. I worry about our children’s general well-being. Kids are less active than normal due to restricted sports and decreased commutes to school. Physical activity is an important component of overall health and known to improve mental health, sleep and learning. I worry that kids will snack a lot at home and gain weight, as it’s been shown that most kids become overweight or obese during school vacations. If kids aren’t vaccinated, attending regular checkups or dental cleanings, they may suffer other preventable complications. We must keep studying and learning, but as a parent and a pediatrician, I think we should put risks in perspective. If 1/10,000 children experience a rare long-term complication, it matters. It’s one child in a medium-sized town and doctors need a plan to optimize their care. But if 8% of children already have significant anxiety or depression before the pandemic and it increases 50% during the pandemic, it’s 1 extra child out of an average class. This change will affect a generation of children on a different scale. The other reason to focus on these more statistically likely complications is that we can mitigate these risks. We can organize our schedules to prioritize sleep and exercise to promote mental health. We can check in with our children and ask for help early if we think their mental health is struggling. We can prioritize preventive healthcare. Let’s do our best to follow facts, not fear.

Pediatric COVID

Guest Opinion Post: Stop Scaring Parents — How to consider the long-term issues facing children

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