In late 2019, a new infectious disease emerged and spread to almost every continent, called COVID-19. As of March 11th 2020 it was declared a global pandemic by the World Health Organisation, meaning that is was being spread among multiple different countries around the world at the same time. It has changed the way we live our lives.
What we understand about SARS-CoV2 and COVID-19 has increased dramatically, with research being done at an extraordinary rate. For those of us whose business is looking after children, what do we need to know?
Editor’s note: This post is based on what we know today, Wednesday 15th of April 2020, and will be updated as new information becomes available.
What is COVID-19?
- COVID-19 is the name of the disease caused by a new coronavirus, which has been named SARS-CoV-2. COVID-19 is the disease, and SARS-CoV-2 is the virus.
- A coronavirus is a type of virus named after its unique appearance – with a ‘crown’ of proteins – when viewed with high power microscopy.
- Coronaviruses very commonly infects humans (and some animals).
- In humans, coronaviruses are a frequent cause of the ‘common’ cold – resulting in an upper respiratory tract infection with cough and coryza. There are, however, three types which can cause severe, even life-threatening disease in humans (SARS, MERS, and COVID-19).
What is the difference between COVID-19, SARS, and MERS?
Whilst they are all severe illnesses caused by coronaviruses, there are some important differences. Some useful things to consider include the R0 (how many people, on average, one case of the disease will spread to in others) and the Case Fatality Rate (CFR), an estimate of how many people who contract the disease will die from it. Neither of these statistics is hard and fast (and are both highly context-specific), but they provide a rough yardstick with which to compare infectious diseases.
- SARS: This is an acronym for Severe Acute Respiratory Syndrome, a disease caused by the virus SARS-CoV. In 2002-3 the spread of SARS-CoV resulted in around 8,000 cases, with a CFR of approximately 10%. Similar to COVID-19, SARS-CoV originated in China, before spreading around the world, predominantly Europe, North America, and South America. The R0 from SARS is thought to be 3.
- MERS: This is an acronym for Middle East Respiratory Syndrome, caused by the virus MERS-CoV . As the name suggested, it originated in the middle east in 2012, transmitted initially from camels to humans. MERS causes the most lethal infection of the coronaviruses, with a CFR of around 35%. The R0 from MERS is thought to be <1.
- COVID-19:This is an acronym for COronaVIrus Disease 2019, the disease caused by the virus SARS-CoV-2. It is a zoonotic disease (meaning it was transmitted to humans from animals) and although the intermediate host has not yet been identified, it’s thought to most likely have originated in bats. It was initially identified in December 2019 in China, before spreading around the world. The CFR is unclear, as it is still uncertain how many people actually have the virus, and how many who currently are unwell will die from the disease. The overall CFR is thought to be about 1.3%. This is highly dependent on the country (and available health resources) but another significant factor is age, with only a handful of deaths reported in children <12 years who have confirmed COVID-19. The R0 for COVID-19 is still unclear but is thought to be 2-3.
What are the symptoms?
- The symptoms of COVID-19 are similar to other respiratory viral infections. Importantly, in children the symptoms of COVID19 are more likely to be mild, and a significant proportion may be asymptomatic.
- Infected children who are symptomatic most commonly present with cough and fever.
- A small proportion of children also present with gastrointestinal symptoms (vomiting or diarrhoea) (~10%)
- Sore throat and runny nose do not appear to be uncommon features in children (as opposed to adults)
How does COVID-19 affect children?
Evidence from across the globe (namely China, Spain, Italy and America), has shown that children are significantly less affected by COVID19 than adults. There are both fewer cases in children, and less children who are severely unwell. Younger infants appear to be most likely to be hospitalised. Overall, there have been only a small number of deaths in children with confirmed COVID-19 reported. A number of epidemiological and clinical papers on COVID-19 in children have been published, summarised on DFTB.
The exact reason why there are so few children with confirmed COVID-19 is unknown. Initially it was thought that due to the high rate of asymptomatic infection children were simply less likely to be swabbed and have confirmed infection. However, recent evidence from Iceland, Japan and Korea shows that children may also be less likely to become infected with SARS-CoV-2 following exposure.
It is yet unknown whether asymptomatic children can pass the infection on to others. In epidemiological studies children have not been found to have a significant role in household transmission. It appears children may continue to excrete the virus through their faeces (poo) for several weeks after the symptoms of infection have passed, but the role of this excretion in viral transmission is not clear (there is some evidence to show it is only viral particles rather than active virus). Regardless, hand hygiene remains of paramount importance in reducing spread.
If my child is unwell, can I give them ibuprofen?
There has been considerable social media interest in the use of ibuprofen in suspected or confirmed COVID-19. In the UK, the MHRA has deemed there is no evidence of increased risk of using ibuprofen even in cases of COVID-19.
What about neonates?
Neonates without comorbidities do not appear to be at an increased risk. A large number of case series having been published of babies born to mothers with COVID-19. Although some neonates have swabbed positive for SARS-CoV-2, there have been no reports of this being associated significant illness. Evidence about the possibility of transmission from mother to baby in the womb is currently unclear.
In the UK, the RCPCH has published guidelines (with the Royal College of Obstetrics and Gynaecology) recommending pregnant women with COVID-19 who are in labour should deliver their baby in an obstetric unit, however there is no need to separate mother and baby after birth, and the benefits of breast feeding outweigh any theoretical risks. Of note, the American Academy of Pediatrics has released conflicting guidelines, suggesting separation of the mother and baby.
What about children with chronic conditions?
There is limited data to guide us currently on how COVID-19 might affect children with underlying health conditions. There are small case studies of children with suppressed immune systems who have not developed severe illness, including children treated for cancer and inflammatory bowel disease. There is some evidence that children with respiratory or cardiovascular comorbidities may be at higher risk of hospitalisation, but it is still unclear. For children currently being treated for cancer, the UK Children’s Cancer and Leukaemia Group have posted guidance for families including which groups are extremely vulnerable and should be “shielding”.
Is there any treatment?
There is no proven treatment for COVID-19, however, there are many clinical trials underway for many different therapies. The WHO has clearly stated that experimental therapies should only be used in the context of a clinical trial. Hydroxychloroquine and remdesivir have been studied most extensively, but there remains no clear evidence of benefit. Importantly, hydroxychloroquine has been associated with significant adverse effects, highlighting the importance of its prescription only in the context of a clinical trial.
Notably, there are only a handful of clinical trials for children registered, so it is unlikely that any therapeutics will be widely used in children with COVID-19. As the disease is generally mild in children, it is not likely to often be necessary to provide anything further than supportive care.
Vaccines will hopefully provide protection against future outbreaks of COVID-19, though these are still early in the drug development pipeline and unlikely to be available this year.
What can I do to minimize my risk?
Two words – hand hygiene. As with other viruses spread by droplet (e.g. influenza) hand hygiene, particularly when out in public, plays a critical role in preventing transmission. Washing hands with soap and water, for an adequate amount of time, covering all areas of the hands is most effective. Hand sanitizer is effective, but no more so than usual hand washing
It is important to avoid contact with others who are acutely unwell. Wearing surgical masks will not protect you from respiratory viruses. Wearing one if you are unwell may protect others from your respiratory secretions.
Physical distancing is becoming increasingly important, with many countries now mandating various ‘lock-downs’. You should follow advice from your public health authorities, and it would be wise to reduce non essential physical or close personal contact with other people to a minimum
What should I do if someone in my family becomes unwell?
- It’s important to try and prevent spread – the best way to do this is to encourage coughing into tissues or elbow, followed by hand hygiene.
- Review local guidelines and contact your local general practitioner or hospital about the best way to be reviewed by a doctor.
- Individual countries have their own systems for managing people in the community who are concerned they may have COVID-19.
Resources for health professionals
Many journals have made their COVID-19 resources open access including NEJM, The Lancet, BMJ, and JAMA
National professional resources can be found at:
- UK: https://www.england.nhs.uk/ourwork/eprr/coronavirus/
- AUS: https://www.health.gov.au/resources/collections/coronavirus-covid-19-resources-for-health-professionals-including-pathology-providers-and-healthcare-managers
- USA: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
For a comprehensive review of all paediatric English language literature to date which has informed this article please see our separate page for COVID-19 Evidence
“It is important to avoid contact with others who are acutely unwell. Wearing surgical masks will not protect you from respiratory viruses. Wearing one if you are unwell may protect others from your respiratory secretions.” The vast amount of scientific evidence of percentage of protection while wearing various masks is well-documented. Not sure why this is downplayed when it could save lives.
Thank you so much for your approach t the current evidence,, the challenge now is in terms of translating this into how we will need to work on the ground. I am very anxious about missing serious illnesses in children assumed to have Covid19 and also how I manage PPE for staff when a really high proportion of patients are likely to be carrying the virus. It would help to have an idea of the numbers others are seeing af all admissions, I had heard in Italy that the total numbers of children seen was less than usual for the time of year. Data like this would really help planning in advance in my large district hospital near Manchester UK
Another wonderful work of summary. Thank you
Text: There is, as yet, no evidence of vertical transmission from mother to child…
With new information, now we know that perinatal infection can occur if the baby is born to a pregnant woman with confirmed infection via vaginal delivery. The cesarean delivery seems to be with less risk of transmission.
Thank you for your comment.
Whilst the article supposes that vertical transmission is *possible* via vaginal delivery, there is no direct evidence of this having occurred as yet. In addition, the risk to newborns is unclear, and given the notably low morbidity and mortality in general in the youngest children, the risks of a cesarean section to mother and newborn may be felt to outweigh the theoretical benefits of reducing the risk of transmission. These factors have all been taken into account in the new UK RCPCH/RCOG guidelines.
There is currently no evidence to favour one mode of birth over another and therefore mode
of birth should be discussed with the woman, taking into consideration her preferences and
any obstetric indications for intervention. Mode of birth should not be influenced by the
presence of COVID-19, unless the woman’s respiratory condition demands urgent delivery.
(Coronavirus (COVID-19) Infection in Pregnancy, Information for healthcare providers. Royal College of Obstetricians & Gynecologist)
We need to learn fast, and with the information available, to have the best outcome in a situation with many questions. Thanks again.