Various Updates and Assessing Risk

The most important update on the COVID in pregnancy space is this letter in NEJM, out sometime last week. The authors report on 215 women who delivered at NY Presbyterian Hospital between March 22 and April 4th. All were tested for COVID-19. Basic results: 4 of the women (1.9%) had symptoms of COVID; all tested positive. 29 women tested positive with no symptoms (13.7%) Later, 3 of those women developed a fever (only 1 was presumed COVID related) (Since I know you will ask: no, they didn’t report infant outcomes. I do not know why not, although I think if there were any bad outcomes for infants they would have mentioned it.) I am a fan of this study for (among other things) the reasons cited in the last newsletter. Universal testing like this of a known population is a helpful benchmark. It’s not random, but it adds a lot of value. There are a few big take-aways. First, these rates are very high. 15% of this population tested positive. I think this is higher than many people would have guessed, although a doctor friend in NY told me thought it was even higher in his patient population. This suggests the virus may be more widespread than we think. Second, a huge share were asymptomatic. Like, almost all of them. This was also surprising, although it’s in line with a lot of what we are increasingly seeing - namely, that a pretty large share of younger people have the virus but no symptoms. Putting these together, I think this study is simultaneously reassuring in some ways and not in others. On the reassuring side, it confirms our impression that pregnant women have mild infection. It’s perhaps even more extreme on that front than we might have expected - depending on how you read the data, between 80 and 88% of these women had no COVID symptoms ever. On the less reassuring side, it does suggest the possibility of exposure at the time of labor and delivery. The high rates of asymptomatic infection generally makes this exposure more likely, since people are walking around not knowing they are infected. My general feeling is this should probably make you more cautious about exposure to others (in particular, vulnerable people like grandparents) in the period after delivery. Many people have suggested to me that their own parents are isolating in advance of birth so they can avoid risk to the baby. This suggest the opposite: it may make sense to isolate after delivery, to avoid risk to grandparents. Babies and Kids: Updates As the epidemic has evolved, it seems increasingly clear that kids are not heavily affected. The CDC now has a helpful website of hospitalization rates by age. A reminder: hospitalizations are much more reliable metric than case counts, especially when we compare by age, since case counts rely on testing and testing varies a lot across groups. The hospitalization rates last week in children 0 to 4 were 1.1 per 100,000 or about 300 total in the US. For kids aged 5 to 17 it was 0.3 per 100,000 or about 160 children. The CDC also reports death information. Between Feb 1 and April 17th, there were 3 deaths among children under 15 attributed to COVID-19. To put this in context (more on context below), there were 4594 total deaths in this age group over this period. COVID is simply a very small share, and a very small overall risk. Risk and Anecdotes When I was writing Cribsheet, I thought a lot about how to talk about risks — especially risks of really terrible things happening. I wrote about Sudden Infant Death Syndrome, and about how to think about putting the risks of cosleeping in context. One of the main things I talked about there was the idea of thinking about how a new risk relates to risks you are already taking, perhaps without thinking about them. Most of us drive cars, while pregnant and with our infants and kids. This activity is risky — it puts us at risk of injury or death. We take that risk all the time, but we don’t think about it. I’m not saying we shouldn’t drive, and of course we should wear seatbelts and use car seats. But the fact is that life involves risk, as hard as it is to face when that risk is of something unspeakable happening to your child. I’ve been thinking about this in the context of COVID-19 since when I talk to pregnant women and parents, they will sometimes bring up scary examples of pregnant women, infants or kids who got very sick or possibly even died. The intense focus on the virus brings these examples to the forefront — women have told me they are consumed by these cases, by the fear they induce. If this is you, and especially if it is affecting your mental health, I would urge you to put this in context. Over these past months when we lost 3 children under 14 to COVID-19, we lost 74 children in this age group to influenza. Both of these facts are tragic, to be mourned. I’m devastated for these families and cannot imagine what they are going through. My heart breaks for them. But the fact is that most people who tell me they are consumed with fear for their children in the face of COVID-19 do not say the same for influenza. I’m not saying you should be terrified of the flu, nor am I saying that COVID is “just the flu”. For older people it is clearly not. But what I’m suggesting is that the constant news cycle here may not be serving us well. Yes, wear a mask and social distance. Don’t be careless with exposure. But being consumed by fear cannot help you cope.

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