Since December 2019, our world was at its most fragile with the emergence of COVID-19, the most significant pandemic in the past century. As of 17 May 2022, COVID-19 has taken 6.27 million lives and infected more than 522 million people worldwide. Our world came to a standstill for two years with global lockdowns, widespread travel restrictions and families torn apart. As the pandemic spread across continents, global health care leaders struggled to manage a crisis that has inevitably laid bare the gaps and inequalities in our healthcare systems as well as the need for global interdependency. As so aptly put by Dr Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization (WHO); “The greatest threat we face now is not the virus itself, it’s the lack of global solidarity and global leadership.” Children have not been spared from the impact of COVID-19, affecting social, psychological and communication development through long periods of isolation, disruption in education and 2 years of lost childhood, a childhood that was meant to be filled with outdoor play, exploration and connection.
What is COVID-19?
Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) is a novel coronavirus that first emerged in Wuhan, China in 2019. Coronavirus disease (COVID-19) is the infectious disease caused by the SARS-CoV-2 virus. Coronaviruses are a large family of viruses that cause respiratory infections. These can range from the common cold to serious diseases requiring ventilatory support The Coronaviruses that circulate amongst humans are thought to originate from animal reservoirs. The most likely ecological reservoir for SARS-CoV-2 is bats, but it is believed that the virus jumped the species barrier to humans from a yet-tobe identified intermediate host.
COVID-19 in Australia
In Australia, as of 17 May 2022, there have been 6.68 million cases with 7873 lives lost. Paediatric COVID cases (aged 0-19 years) make up 813 142 of the total cases (12%) with a total of 13 deaths, predominantly in children less than 10 years of age. These data are consistent with international reports. Pre-school and primary school children appear least likely to acquire the infection and make up less than 5% of reported cases.
How is COVID-19 transmitted?
The principal mode of transmission of COVID-19 is via exposure to respiratory droplets carrying the virus. Exposure can occur in three ways:
- Inhalation of air carrying very fine droplets and aerosol particles containing the virus with the greatest transmission between 3 to 6 feet (exhalation, speaking, singing, exercising, coughing, sneezing)
- Deposition of droplets on exposed mucous membranes (i.e. mouth, nose, eyes) by direct splash or sprays (coughing, sneezing, kissing)
- Touching mucous membranes with soiled hands either directly by respiratory droplets or indirectly by touching surfaces with the virus on them
According to the CDC, a person is considered infectious 2 days before they start demonstrating symptoms and 5 days after being symptomatic if mild or asymptomatic. If moderately or severely ill, they can continue shedding up to 20 days due to replication-competent virus.
COVID-19 in Children
When it comes to children, the iconic article “Modes of transmission of respiratory syncytial virus” by Hall and Douglas, better known as “Cuddlers, Touchers, and Sitters”, best depicts the behaviour of respiratory viruses in children. It is important to note children of all ages are infectious and carry the same risk of transmission as adults, whether they are symptomatic or not. Moreover, the younger the child, the more likely they are to transmit COVID-19 to others once infected.
Young children demand attention and cuddles when they’re sick. They know nothing of social distancing or coughing etiquette, despite what we try and teach them. They will have nasal fluid streaming down their face and will be covered in copious infected secretions. This is an easy opportunity for transmission.
Clinical Features of COVID-19
The clinical spectrum of COVID-19 is broad but the typical symptoms can be classified into respiratory features (cough, coryza, sore throat), gastrointestinal features (vomiting, diarrhoea, abdominal pain) and general features (fever, headache, lethargy). While COVID-19 has proven to be milder in the paediatric population there are a number of risk factors for more severe disease. These include immunosuppression, underlying chronic disease, obesity as well as age, which forms a “u-shaped” risk gradient with infants and adolescents being at higher risk.
Examination findings are usually associated with the presenting problem. Respiratory related signs include increased work of breathing, tachypnoea (elevated respiratory rate) +- cyanosis (bluish discolouration of lips and/or peripheries) depending on the severity of distress. The other important sign to assess is hydration status (mild, moderate or severe) as most sick children have reduced fluid intake despite not having any gastrointestinal losses. Hydration status is important for infants as they have higher baseline fluid requirements (due to a higher metabolic rate), higher evaporative losses (due to a higher ratio of surface area to volume), and an inability to communicate their thirst.
At present, all children who meet testing criteria (which vary according to state in Australia) for COVID-19 should get tested. Other investigations depend on clinical need.
Lymphocytopaenia is relatively rare in children compared to adults. Like adults, they may also have a mild elevation of inflammatory markers and liver transaminases. Chest x-rays are often normal. Therefore, there is no clear way of differentiating COVID-19 from any other childhood respiratory virus infections, or other benign childhood illnesses clinically.
Disease Severity Classification
These definitions were created via a consensus process and can be found in the Australian Guidelines for the Clinical Care of People with COVID-19. The vital sign parameters should be considered within the context of normal age‐appropriate ranges for neonates and children, and/or any pre‐existing illness.
In Australia, the National COVID-19 Clinical Evidence Taskforce is a coalition of health professional bodies that update the Australian Guidelines for the Clinical Care of People with COVID-19 as new evidence emerges. We’ve summarized the latest guidelines for children and adolescents (as of 15 May 2022) below:
Disease Modification Therapy
- Steroids: Inhaled (Budesonide or Ciclesonide), Oral (Dexamethasone)
- Consider inhaled steroids for children NOT on oxygen support and are at higher risk for disease progression and oral steroids for children on oxygen support
- Antivirals: Remdesivir or Nirmatrelvir plus Ritonavir (Paxlovid)
- Only considered for children NOT up to date with vaccination or immunocompromised
- Other considerations based on risk factors and disease severity:
- Human Monoclonal Antibodies: Casirivimab plus Imdevimab (Ronapreve), Sotrovimab, Tixagevimab plus Cilgavimab (Evusheld)
- Immunomodulators: Baricitinib and Tocilizumab
National COVID-19 Clinical Evidence Taskforce: Flowchart on Drug Treatments for Children and Adolescents with COVID-19.
Venous Thromboembolism Prophylaxis
In the adult population, there have been worries around an increased risk for venous thromboembolism. Therefore, all children and adolescents admitted to hospitals for COVID-19 are commenced on local thromboprophylaxis protocols. Trials on this population are underway and recommendations will be updated once new evidence is available.
The task force has carefully evaluated the choice of respiratory support and escalation of care. They have made 10 recommendations including when to use non‐invasive ventilation, management of the deteriorating child (including intubation and approaches to intubation), prone positioning, mechanical ventilation strategies and the use of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation.
The task force has also listed treatments that are NOT Recommended which include aspirin, azithromycin, colchicine, convalescent plasma, hydroxychloroquine, hydroxychloroquine plus azithromycin, interferon‐β‐1a, lopinavir‐ritonavir, interferon‐β‐1a plus lopinavir‐ritonavir and ivermectin.
* Further information from the drug treatment flowchart for COVID-19 in children and adolescents has been attached below. The recommendations above are current as of 15 May 2022; any updates since publication are available at https://covid19evidence.net.au/.
Paediatric Inflammatory Multisystem Syndrome (PIMS-TS) and COVID-19
Although COVID-19 disease is milder in the paediatric population, a rare but life-threatening complication seen in children is Paediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2 (PIMS-TS). It is a hyperinflammatory syndrome that appears to be a delayed immune response to COVID-19 that occurs 2-6 weeks after infection. The median age is 9 years but can range from infancy to adolescents. Risk factors include male gender, race/ethnicity other than Anglo-European and children with obesity. It has an incidence of around 1 in 3000 children who have tested positive for COVID-19.
PIMS-TS should be considered in unwell children with fever for 3 days or more, signs of shock, rash, and gastrointestinal symptoms (abdominal pain, diarrhoea). Several features overlap with Kawasaki disease and toxic shock syndrome. Interestingly, they do usually not present with respiratory symptoms. Laboratory findings are consistent with an inflammatory with elevated CRP, neutrophilia, and lymphopenia.
Management of PIMS-TS can be summarised in the following:
- First line: IVIG +- Corticosteroid (methylprednisolone)
- Second line: Corticosteroids- if not given with IVIG
- Third Line: Immunomodulators (Anakinra, Infliximab, Tocilizumab)
- Low dose aspirin
These children still require follow-up after discharge to ensure no long term cardiac complications.
Long COVID-19 in children
There is limited data on long COVID in the paediatric population. There’s no standard definition but symptoms persisting for more than 4 weeks following the onset of COVID is the current consensus. The most comprehensive paediatric study to date was done in the UK. It looked at 1734 children aged 5-17. It showed that 4.4% of children reported ongoing symptoms after day 28 of illness. This dropped to 1.8% by day 56. Three-quarters of these children went on to a full recovery. Unfortunately, the other quarter was lost to follow-up.
There are three broad constellations of symptoms associated with long COVID, namely cognitive effects (the slowed thinking or “brain fog”), physical symptoms (including fatigue, breathlessness and pain) and mental health symptoms (such as altered mood and anxiety). The cumulative effect of long COVID can have a detrimental impact on the child’s ability to function in their daily life, work, or schooling. These children need a multidisciplinary approach with the aim of incremental gains and a gradual return to normalcy.
Although children have been less physically affected, the same can’t be said about their general wellbeing. For infants and toddlers, developmental delays may have been missed due to a lack of regular face-to-face consultations. This may have, in turn, lead to delays in treatment and therapy. With hospitals being overwhelmed and reduction in the number of outpatient clinic appointments, those chronic medical conditions requiring close follow-up may have been missed, leading to more frequent ED presentations and hospitalizations
Children’s Mental Health and COVID-19
The biggest impact seems to have been on the mental health of our children. Psychiatric conditions went undiagnosed for months. There has been a degree of separation anxiety and worry for parents who are frontline workers. More significantly, those who have lost parents to the disease suffer from grief and are susceptible to developing post-traumatic stress disorder. Any adverse childhood event can cause the body’s natural stress response to become dysregulated. This may lead to a delay in cognitive development, somatic complaints, obesity, asthma, diabetes, recurrent infections, sleep disturbance, and even premature death. We also saw a surge in use of electronic devices due to social isolation and home confinement which are not without its own drawbacks. A few vulnerable ones fell prey to the Internet, with sexual predators lurking in the deep corners of the web. Cell phone addiction is at its highest with some facing difficulty adapting as the immediate crisis passes.
Parental stress directly affects their children and unfortunately the incidence of intimate partner violence has been on the rise whilst access to help and support has grown more difficult because of lockdowns.
Learning to Live with COVID-19
As Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure.” The best way to help our children stay safe can be summarized as follows:
Vaccination: Single most effective tool available to prevent infection in children and adults. Young children who cannot receive a vaccine are protected by the vaccination of adults and older children around them.
Education Hand hygiene: Wash their hands with soap and water often and thoroughly (for at least 20 seconds) to prevent viruses entering their body. This includes after being out in public, before eating, and after going to the toilet.
Cough etiquette: Cough or sneeze into a tissue or their elbow (and wash their hands and put the tissue in the bin afterwards).
Physical distancing and crowd avoidance: Avoid crowded places, poorly ventilated, indoor locations and avoid prolonged contact with others. Try to stay at least 1.5 meters away from people who are coughing or sneezing.
Early testing: Have a high index of suspicion when close contacts are unwell and get tested. Heightened precaution leads to reduced risk of transmission.
Clinical Pearls: Paediatric COVID Vaccination
- In Australia, currently approved COVID-19 vaccines for children between 6-11 years are Pfizer and Moderna. Pfizer is the only approved vaccine for children 5 years of age.
- The recommended schedule for both vaccines are 2 doses, 8 weeks apart.
- Paediatric COVID vaccinations CAN be co-administered with other vaccines.
- Side effects: injection site pain, headache, fatigue, fever (usually 3-4 days after administration).
- Adverse effects: myocarditis and pericarditis with both vaccines with a higher incidence in adolescent males. While most myocarditis and pericarditis are self-limiting, some children require specialist input. An adolescent who presents with chest pain, shortness of breath, palpitations, syncope, or dizziness within 1 to 14 days of receiving COVID-19 vaccine requires thorough evaluation.
Although the public health aspect of COVID-19 may be in recovery phase in some countries, the socioeconomic impact that has afflicted billions of people will take months, if not years, to recover. As borders open, travel restrictions ease and our world appear to be making a slow transition back, we are now in the ‘new normal’ and our way of life pre-COVID is gone and needs to be forgotten. Even with the widespread distribution of vaccines, experts have suggested that we need to prepare for endemic resurgences of the virus in the future. We must all work together to ensure our most vulnerable children are cared for.
NSW Government: Children’s Book About Coronavirus
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