The COVID-19 Pandemic and our Children
I have been asked a lot lately about my individual views on the safety of the return to school. This document discusses some facts about Children as they relate to COVID-19, presentation in children, transmission, current recommendations and things to consider in sending your children to school.
Some facts about Children as they relate to COVID-19 infection:
The majority of children with COVID-19 have a positive household contact.
Children have been found to have high viral loads but despite this they tend to have milder symptoms.
Children, especially younger children up to 9 years old, seem less likely than adults to transmit the virus to other children or to adults. This could be due to smaller lungs that do not cough as forcefully (can’t propel virus-laden droplets as far), or perhaps that children produce fewer angiotensin-converting enzyme 2 (ACE2) receptors (responsible for allowing viral entry into cells).
It seems that children from 10 to 19 years old have a more adult-like capacity for transmission.
At this time, there is no definite evidence of transmission of COVID-19 from a pregnant mother to an unborn child i.e. what is termed vertical transmission. Postnatal transmission (transmission to the child after birth) from a caregiver is more likely to occur.
What is the Multisystem Inflammatory Syndrome in Children?
Since May 12, 2020 there have been warnings of reports an acute inflammatory syndrome temporally linked to COVID-19 that has been reported in children and teenagers. Children with this condition present with symptoms of systemic inflammation, and can have clinical similarities to Kawasaki Disease, toxic shock syndrome and macrophage activation syndrome. Prominent features include fever, abdominal pain, cardiac involvement and rash, among others. There may be a spectrum of disease severity. This condition has been given the name Multisystem Inflammatory Syndrome in Children or MIS-C. If MIS-C is suspected the child warrants urgent evaluation by a Pediatrician or Pediatric team experienced in diagnosing the above listed inflammatory conditions as a first step. If suspicions are high, consultation with pediatric rheumatology, cardiology, infectious disease, and critical care is recommended, ideally at a tertiary pediatric centre. If your child has had a fever greater to or equal to 3 days not responding to simple at home measures to reduce it and they have gastrointestinal upset (significant abdominal pain, vomiting or diarrhea), rash, pink eye, redness or peeling of the mouth, lips, hands or feet, symptoms suggestive of hypotension (light headedness or faintness), please seek medical attention by calling your primary healthcare provider or 811 for direction.
What about cases in children?
Current literature suggests that most children will have mild disease and will recover at home 1-2 weeks after symptom onset with no medical intervention necessary. Suspected or confirmed cases should self-isolate at home for at least 10 days after onset of their symptoms. After 10 days, if their temperature is normal and they feel better, they can return to their routine activities. Coughing may persist for several weeks, so a cough alone does not mean they need to continue to self-isolate for more than 10 days.
Some specific recommendations are now discussed. The BCCDC (BC Centre for Disease Control) currently recommends:
How can I manage my child’s fever? Children’s Tylenol and ibuprofen at routine doses can be safely administered for fever and symptom relief in children with suspected or confirmed COVID-19. There have been concerns that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen may worsen the severity of COVID-19 infection. However, the evidence for this has not been substantiated.
Can steroids be used? Corticosteroids are not recommended as a treatment of COVID-19 but should be administered in situations with established indications. There are potential side effects to using Corticosteroids specifically to treat COVID-19, however where disease condition which usually require the use of steroids exist, these medications can be used safely under the guidance of a licensed Physician. For example, children with asthma exacerbations or cases of croup and suspected/confirmed COVID-19 should receive their steroid inhalers or oral steroids according to current guidelines.
How about the use of Antibiotics? Antibiotics have no effect against the COVID-19 virus. It is a virus. When Physicians or hospitalists are prescribing antibiotics in cases where there is proven or suspected COVID-19 infection, it is to treat any possible co-existing bacterial infection.
How about the use of Antivirals? There are currently no approved antiviral therapies to treat COVID-19. As per the WHO (World Health Organization) guidelines, investigational anti-COVID-19 medications will only be used in approved, randomized controlled trials (RCT). Examples you may have heard about include: Oseltamivir – this is not recommended for COVID-19 as it is highly specific to the influenza virus. Lopinavir/ritonavir – this has been shown to inhibit the activity of coronavirus. It is currently in an RCT. Remdesivir – this is currently being studied as a potential treatment option for severely ill patients with COVID-19. Its safety and efficacy in this disease is not yet established. Chloroquine/hydroxychloroquine – this appears to decrease the COVID-19 virus’ ability to enter cells and is thought to modulate the immune system but only in severe disease. However, the studies of it were grossly limited and the potential for significant side effects was noted. It cannot be recommended at this time.
Can intravenous antibodies known as IVIG (intravenous immunoglobulin) be used to treat my child with COVID-19? This is not recommended as a treatment of acute COVID-19. IVIG has been used in some pediatric cases of COVID-19 but there is no clear evidence of benefit in COVID-19 disease in children.
Should I send my child to school?
In making the decision to send your child to school, you should consider the following:
What is in my child best interest, not just physically but also mentally, emotionally and socially?
Does my child going to school bring added complexity or difficulty for my family and household members?
Can all of the needs my child has in school be met at this time?
Does my child have proven immune deficiency which is currently affecting their health status? In considering this question ask yourself, if there were not a COVID-19 pandemic, would my child’s health status prevent them attending school?
How long can I continue with an alternate arrangement to meet the demand of tutoring and learning?
Have you asked your child how they feel about the current climate, COVID-19 and their health? Have you really listened to their answers?
What options are my child’s school and school district offering? If you are confused about this, have you reached out to the discuss any complexities in your circumstances and reasons you are seeking further options? Please remember that whichever school your child is attending, they are struggling with all of the same questions you are, and this is multiplied by all the children they are responsible for. You should only reach out with questions regarding complexities to your child fitting in with current proposals and if you have been unable to find answers on the resources put out for us all to access.
People keep saying there needs to be an adjustment to this new normal, but there is nothing normal about this situation we are in. But the truth is as parents we are always evaluating what is best for our children and our families. These are just the new set of circumstances to work in. The difficulty is we are so unfamiliar with some of these considerations and the landscape keeps changing. The message is still simple; stay safe AND keep healthy. Education and developmental consideration are important aspects of health. The reality is that the current situation caused by this COVID-19 pandemic is here to stay for a while. The balance between keeping our children safe and healthy is ever so important.
Remember, we are continually gaining and learning more about Covid-19 and therefore, it is important to keep up to date with new information by: listening to our BC Health offices, checking the CDC, and remaining engaged with health care teams and professionals involved in your child’s care in order to receive the most accurate and up to date information.
What do we practically have to do when it comes to transmission of COVID-19?
With all of the terms out there in relation to COVID-19, it is important to clarify some terms in relation to transmission. These are terms that are being used very much today.
The Incubation period is a median of 3-5 days but ranges from 2 to 14 days. This is the science from which governments use to determine the Isolation period one needs to abide by if they are exposed to COVID-19 or travel into a new jurisdiction requiring isolation prior to mingling with the new community. The Incubation period is the time whereby someone is at risk of developing symptoms of COVID-19 due to potential exposure and after which it is highly unlikely to happen. For most jurisdictions this is usually regarded as 14 days. This is why those with potential exposure are asked to self-isolate for 14 days. The Infectious period however describes the period of time when a person has developed symptoms of COVID-19 and remains contagious to others. It is regarded as a 10-day period from the onset of symptoms. Therefore, if a person develops fever on day 1, a cough on day 3 and diarrhea on day 5, they remain contagious for 10 days from the day when the fever started, i.e. day 1. Here the Isolation period would therefore be 10 days. If the person remains ill after that 10 day period, they are regarded as non-infectious in terms of COVID-19 but obviously if there was additional exposure to COVID during this 10 day period, that person would have to start an Incubation period and Isolation period for 14 days from the day of exposure. If there was no COVID exposure but the person is still unwell after 10 days, a sensible approach to re-mingling with the community should be exercised as there could be many other infectious causes other than COVID-19. Appropriate actions therefore should be taken.
What happens if a COVID-19 test has been done and is negative?
If the person has symptoms or they have travelled outside of Canada in the last 14 days, then they should have an Isolation period for 14 days. If the person no longer has symptoms, that is they have resolved, then they should have an Isolation period for 10 days. These actions would also be true if a person presents with symptoms of COVID-19 and has not been tested.
What happens if a COVID-19 test has been done and is positive?
Public Health will contact the person and advise them on their next actions, and this will likely be the person having an Isolation period for 14 days whether or not the person has ongoing symptoms. Self-reporting and follow-up on clinical condition arrangements will be made. It is true to note that the person will remain infectious for 10 days from the onset of the first symptom however, what must also be considered is that positive cases of COVID-19 in asymptomatic people have been documented. Therefore at least in some jurisdictions, including ours the Isolation of 14 days in this case scenario is the likely option to be recommended.
Dr. Kevin Ansah
BC Centre of Disease Control