The coronavirus is here and parents have questions about the threat COVID-19 poses to the health of their children. As of now, answers have not been satisfactory, consistent, or satisfactorily consistent. Early studies out of China suggest that though mortality rates are low — though still highly worrisome at a population level — novel coronavirus does pose a serious risk to children as well as the elderly, specifically some children with pre-existing conditions. That said, all children can be vectors for the disease and scientist have not yet uncovered any patterns in infection that might justify complacency. Outcomes among infants, in particular, have been varied and have many front-line medical workers we’ve spoken to are worried.
This story, which will be updated frequently until scientific consensus is reached on the questions posed, is intended to be an up-to-date accounting of what epidemiologists, doctors, and public health workers know so far. All quotes are timestamped because available information is becoming outdated rapidly. Answers should be understood in light of that fact. Just because we believe we know something now does not mean that thing is true. A lot of hypotheses have yet to be tested. In the meantime, the best approach is to maintain social distance and to stay informed.
Will coronavirus kill or hurt my kids?
Dr. Logan Spector, Division Director and Professor, Pediatric Epidemiology and Clinical Research at University of Minnesota, March 24, 2020 (5PM): When it comes to young children, my biggest takeaway is that most severe cases [of COVID-19 in young children] were suffered by children with very serious conditions. In the New England Journal study, three severe cases had leukemia, hydronephrosis, and intussusception. So my takeaway from that is that even among children, the worst cases require comorbidities to have the worse outcome. My day job is studying pediatric cancer and I can tell you it’s not especially common.
Dr. Neel Shah, Director of the Delivery Decisions Initiative at Ariadne Labs and assistant professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School March 20 (1:30PM): There are some neonatal transmissions, but it doesn’t seem like infants and neonates are severely affected. We think of people who are pregnant and infants as vulnerable. But we mean that in a lot of different ways. Simply because they’re not likely to be severely infected does not mean they aren’t affected.
Strains on the healthcare system mean ambulatory services are shutting down, prenatal and postpartum support is being shut down. Social distancing impacts pregnancies too. It’s simply harder to get labor support — from doulas or even family members. And there’s always been concern about social isolation after having a baby. Even more so now.
Barun Mathema, Assistant Professor Epidemiology Columbia University; March 22 (11AM): The most recent evidence from China that shows that children are vulnerable, or at least more so than previously thought. Younger children being a higher risk for more serious clinical symptoms than older children. It appears that mortality is still somewhat rare among children.
Barun Mathema, March 18 (11AM): I’ll preface this by saying we’re all confused. Initially, it was confusing that kids weren’t hit because we were wondering if the disease would follow the patterning of pandemic influenza where the curve is a beautiful bell with age on the bottom. Seasonal flu is the opposite, a u-shape. And initially, this didn’t fit either scenario. COVID-19 seemed like a geometric curve from low to high in terms of severity, but now that picture is getting muddled. We’re seeing folks under 50 with morbidity. We’re seeing teenagers and younger kids with fairly severe symptoms.
There was a sliver of pediatric cases and a sliver of pediatric deaths in China. Kids get colds a lot so there was a theory that some are caused by coronaviruses and so there’s partial immunity. There was also the thought that the ACE2 receptor might not be well expressed in children so there could be inefficient entry. Arguably we should be seeing a huge surge in cases, but questions remain unresolved. One can simply say that given a large sample size and a small morbidity, we’re still talking about a big number.
Dr. Jan Dumois, Pediatric Infectious Diseases physician at Johns Hopkins All Children’s Hospital. March 16, 2020 (4:30PM): “There’s a new article where they review 2100 kids who were suspected to have COVID-19. There was one child who died — teen. Only one. Otherwise, all the other kids survived, but they did have different degrees of severity of illness. Sicker kids tended to be younger and needed more aggressive medical care before they were sent home. … not just showing up to the emergency room and being sent home. Patients who ended up in hospital because they needed oxygen. Or they were found to have pneumonia. Then there were some uncommon cases that needed to be on a respirator. Younger children are more likely to be sicker and require hospitalization. Or to be on a ventilator. Sometimes heart. Or the dysfunction of the kidney. It was more common in children less than one. “
Ryan Demmer, PhD, University of Minnesota Division of Epidemiology and Community Health. March 16, 2020 (11AM): Kids who had preexisting conditions, particularly chronic or complex medical conditions, were more likely to have adverse medical outcomes and more likely to have severe ones at that. The co-morbidities that seemed to be the most troubling are with asthma and cystic fibrosis. Children with upper respiratory disease seem to be at risk.
While the absolute numbers are low in terms of mortality among young people, there’s a .01 percent mortality rate for flu in youth and early numbers in kids with COVID-19 put the figure around .2. That’s not high, but it’s a 20 fold-increase. If I told you a plane was twenty times more likely that other planes to crash, you would not get on that plane.
How can I avoid getting the virus?
Barun Mathema; March 22 (11AM) I think the basic rule of thumb is keeping the kids in situations where there is very little density — and certainly keeping the hands clean. So this may be easier in peri-urban or rural locales. Personally, having kids run around outside is really important for general physical and mental health (also for the parents) but not having much or any physical contact would be the goal – this includes surfaces that may be contaminated. It’s hard not to be preachy about things but I will try to politely keep my distance and also explain that even if we do not personally feel at risk, our behavior can (without malintent) put members of our community at risk….we may not even know who is at risk.
Barun Mathema; March 18 (11AM): Just because the elderly and folks with preexisting conditions are vulnerable doesn’t leave everyone else off the hook. This is a serious infection. We read about asymptomatic carriers and minor disease and, yes, many people have had it and will without even noticing. That’s true. It’s also true that three to five percent of otherwise healthy individuals will end up with a serious disease that could require ventilation. Many will recover but it will be an uphill battle. Social distancing and flattening the curve are the answer to this, especially given that a middle-age group will wind up responsible for taking care of most people.
Juan Dumois, March 16, 2020 (4:30PM): The biggest study was able to detect some patients that had no symptoms but were infected. Found quite a few of those. Almost 100. The study wasn’t really designed to look for asymptomatic kids. That study hasn’t yet been published.
When should I get my kid tested?
Barun Mathema; March 18 (11AM): Public health is a very socialist approach. It means health for all trumps health for the individual. This is the antithesis of precision medicine. At this point, as a parent and a public health person, I feel that if a kid is exhibiting alarming symptoms — not a runny nose, but maybe a fever or something that looks unlike a regular cold — parents should consider taking the kid in. But, on some level, it’s important to recognize there’s nothing you’d do differently if your kid tested positive. If children are heavily symptomatic, take them in and get them admitted. Otherwise, you’re going home and observing. Still, there’s some virtue in knowing that you likely have it and that other people in your network likely have it as well.
Georges Benjamin, March 18, 2020: That’s up to every doctor right now. They’re not testing very many kids. I think most kids are only being tested when there’s an emergency. Call the number in the community you’re given, usually the local health department, because these guidelines are changing literally every day.
Sophia Thomas, March 18, 2020: If they have a fever, if they have a cough, they should contact their medical provider to see how they want to handle this. A requirement for testing is patients have to have a negative flu test. With children, oftentimes you would want to do a Strep test as well. If those tests are negative, then they may be eligible to have a COVID-19 test. However, because of the relative shortage of tests right now, different medical practices are doing different things. Some are having to prioritize using the test for the most vulnerable or the ones that have most potential for complications.
Dr. Juan Dumois, Pediatric Infectious Diseases physician at Johns Hopkins All Children’s Hospital, March 16, 2020 (4:30PM): One of the main things that’s going to be changing the way we deal with the pandemic is the availability of testing. It will become more available as the weeks go on. We have more availability this week than last. And tons more this week… some are doing it in their hospitals. We hope to be able to do that test sometime in the next month. As the ability to rapidly and readily do a test where you get results in a few hours and a few days will change the dynamic of people we aren’t currently testing.
Something that might happen int he next six months would be a doctor in the clinic to swab a patient’s nose and get results the next day. Right now we can’t offer the test to everybody and it’s taking 5 days to get results back.
My child has the virus. Now what?
Georges Benjamin, MD, Executive Director of the American Public Health Association. March 18, 2020 (2PM): When kids get really sick, they often don’t eat enough and they often don’t drink enough. Usually, you can coax them to take small sips of water throughout the day. The most important thing is making sure the kid isn’t very, very sick and doesn’t need medical care right now. Most kids do just fine with this.
Sophia Thomas, March 18, 2020 (11AM): Certainly children right now are catching COVID-19, but they are less likely to have complications. Those are children who just need to be isolated for 14 days. If you suspect your child has the virus, you can simply just keep them at home and care for them unless they start having serious problems such as breathing difficulties.
Barun Mathema; March 18 (11AM): I have kids. If they got it, as a public health person, I would be more concerned about them giving it to someone else. Let your healthcare provider know and then basically take care of your child and enhance social distancing. If you have a nanny, give them a call. The health department doesn’t have the capacity to do that.
I have coronavirus, now what?
Juan Dumois, March 23, 2020 (3:30PM): I think a lot of physicians in infectious diseases are hopeful about some of the treatments being investigated for the sickest patients with COVID-19. And while the official stance is there are no proven drugs (and this is correct) there are promising drugs that are being tested on patients with COVID-19. Unfortunately, we’ll start seeing shortages of all these drugs if we do find drugs that kill the virus.
Elisa Choi, MD, Internal Medicine & Infectious Disease Specialist at Atrius Health. March 23, 2020 (8:30AM):`If someone is having significant difficulty breathing, they may need to get further assessed, and home treatment may not be appropriate. Likewise, if someone is having very high fevers, it may be important to get them evaluated. But if someone can be safely managed at home, at this point in time the management strategy for someone who is either suspected of COVID-19 or has confirmed COVID-19 is supportive care and symptom management. So, for example, if someone has a mild cough, you can try over-the-counter remedies to manage that cough. If someone is having muscle aches, again it would be over-the-counter remedies to manage all of those symptoms.
Barun Mathema; March 18 (11AM): This is a tough question. If you have coronavirus and kids you get tested and you find out that you’re positive. At that point, you can assume that a fraction if not all household members are positive. It’s different if you’ve flown in or been screened prior to symptoms. So you may want to self-isolate. But those lines are blurring. All the quarantining will be a moot point because we’ll all be there. The question is just how extreme or expansive. It’s a guessing game, but you want to isolate you and probably your family.
How scared should I be for my parents?
Elisa Choi, March 23, 2020 (8:30 AM): COVID-19 might have increased the risk of significant complications in older individuals, including the worst complication, which is death related to COVID-19. It is understandable that many adults may worry about their elderly parents with COVID-19, particularly since we don’t have a vaccine for this illness, and there is, as of today, nothing that has been concretely proven as a successful therapeutic. It’s very reasonable to be worried. That being said, the majority of people who contract COVID-19 do tend to have relatively milder symptoms. However, if an adult has specific concerns about their parent because they may have multiple other chronic illnesses or might be immunocompromised, which are some other risk factors for more severe COVID-19 disease, it’s certainly worth being particularly mindful of the current recommendations for minimizing spread of COVID-19. If an adult has concerns about themselves having COVID-19, they should reach out and seek clinical evaluation sooner rather than later, particularly if they are a caretaker of their older parent or are living in the same household as their older parent.
Dr. Alicia Ines Arbaje M.P.H., Ph.D. Director of Transitional Care Research, Johns Hopkins Medicine, March 19 (5 PM): Generally we should be concerned about how health systems can respond to the surge of people coming in. People who are coming to the hospital should be the sickest. If it so happens that they should be older, that is what it is. People who are having milder symptoms should be managed at home. It’s more level of need and not so much level of aid. ERs are set up to triage people appropriately. My biggest concern is that we don’t have the supplies or staffing to help care for people when they come. We haven’t gotten to that point yet, but it’s a real concern. How are we going to mobilize our resources?
Dr. Mary Tinetti, Professor of Medicine and Public Health and is Chief of Geriatrics at Yale School of Medicine March 19, 2020 (11AM): We should be very worried. Most of the data we are able to look at are coming out of Italy and some modeling epidemiologists are doing in the rest of the world is showing positive testing in all age groups. But who is getting seriously ill? The vast majority are people 60 and older. The key in focusing on 60 and older is for their own good and the good of everyone else. They’re more likely to use healthcare resources. More likely to die. All the care consumed by them may limit care for younger people.
For this population especially, the more social isolation the better. This means if you’re over 60 especially don’t go out in public, don’t be within 6 feet of anyone, get deliveries or get someone else to drop off your groceries and medications, and get tested if you can. If we start looking at the asymptomatic 60 year old we’ll see how serious it is. Once it’s available. All localities are prioritizing. The more we know the better. So get tested.
Sophia Thomas, March 18, 2020 (2PM: This is a virus that knows no social barriers, and we do know that older people and people with comorbid conditions including hypertension, heart disease, COPD and asthma tend to have worse outcomes. So all grandparents — anybody over the age of 60 — should take this very seriously and practice social isolation. My mother was going to come and visit me and I just told her stay where you are. We’ll FaceTime and I’ll see you next month.
Dr. Logan Spector, March 18, 2020 (11AM): Look to Italy. One of the reasons it is hit so hard is that it had one of the oldest populations in Europe. I really doubt that’s going to change at all. There have been nearly 200,000 reports and we can say with pretty good statistical certainty who are impacted and it’s very clear the elderly are hardest hit. It’s still not clear to me how much of that is just reduced immune function versus co-morbidities. The older you are, the more likely you are to have a pulmonary disease that compounds the effect of a respiratory virus. But there is still a risk in older people who don’t have co-morbidities. That points to lower immune function as we age.
Ryan Demmer, March 16, 2020: I think we should move forward with caution because mortality rates aren’t just linked to the properties of the disease. They are often a product of the environment or context of the disease. China is not America. In America, we have varied healthcare access and high rates of asthma. That could portend worse outcomes in this country. I should state clearly that there’s no evidence of that yet, but we should be cautious.
When will things go back to normal?
Dr. Logan Spector March 24, 2020 (5PM):“Once you let your foot off the brake of social distancing, will you have resurgent cases? Almost certainly. If we all stayed in our houses we would squelch this thing. The virus would die with that. If there are still people out and about who are infected, it will be reintroduced. That’s always been acknowledged. The idea is to spread it out enough to make sure we have healthcare capacity and give the medical community some time to manufacture PPE and develop a vaccine. Let’s just say that any politician — really anyone — who thinks he knows better than virologists and epidemiologists at this point doesn’t have his head on straight.”
Juan Dumois, March 23, 2020 (3:30 PM): Over the last several day I’ve been looking at some of our local COVID-19 patients (in the Tampa Bay Area) who tested positive The numbers are still relatively small, and I suspect that may be a benefit of the social distancing we’re doing. That makes me optimistic. We may already be having a positive effect. However, i don’t think anyone should be lulled into complacency or thinking that this will be over soon. We need to bear it out for several more months.
Elisa Choi, March 23, 2020 (8:30 AM): Where we are now is the infection and the illness is spreading. I’ll speak to Massachusetts because that’s the state I’m in. The number of cases is increasing daily. So we’re in the phase of the illness where there’s still exponential rise in new cases. Now definitely is not a time where we can scale back on measures to mitigate the spread of infection. It’s really hard to give a firm number or a firm timeline of when all of these kinds of measures can be retracted. My sense of how this would play out, though, is once there’s a plateau reached in terms of how many new infections are being detected every day, there may need to be some gradual reduction in some of the current mitigation measures. And it may not be able to be done all at once. It will need to be determined as we get to that plateau point. How long that will be is uncertain. If we reflect on what’s happening in some of the countries in Asia where they have reached that point — China would probably be the best example — it was about two or so months before they got to that point. Things may be different in the U.S. and things may be different moving from state to state in the U.S.
Georges Benjamin, March 18, 2020 (2PM): We don’t know. There are estimates out there that this could go anywhere through a month or two. Those are probably reasonable assumptions. A month or two does not necessarily mean that all of us will be sequestered for a month or two. We just don’t know. We’ve never done this before.
Sophia Thomas, DNP, President of the American Association of Nurse Practitioners. March 18, 2020 (2:30PM): I think this is our new normal for a while. I heard something yesterday that the CDC anticipates that the peak of this might be in May. I think for the next six to eight weeks we’re going to be dealing with this. I don’t anticipate a resolution anytime soon. If people really stick to the social distancing and listen to the advice of the CDC, we could actually see this resolved much sooner by limiting people’s exposure.
Logan Spector, March 18, 2020 (11:10AM EST): Obviously this is unprecedented in modern memory. Everyone is talking about the 1918 flu pandemic and there a lot of the same characteristics as most flu, but the problem with COVID-19 is that there seems to be asymptomatic transmission. Isolating people with symptoms is a first response — and it’s a logical one. When SARS and MERS came out, this was done as well. But those did not seem to have asymptomatic transmission. I think everyone is trying to do their part including those working from home, but it will take time.
Ryan Demmer, March 16, 2020:From a population health perspective the main issue remains not infecting others. There’s no evidence kids don’t get infected or transmit, just that they’re less effected by the disease. Our key goal has to be social distancing. The growth curve is still coming.
The question is where the peak will be. Probably May-ish. And I’m not saying it’s going to go away…. After the peak, we’ll start coming down. What I’m interested in from an ecological point of view is what’s happening in South Korea and Wuhan. They’re saying there’s one case in the province which I find dumbfounding. And there was an impressive decline in South Korea. So if that’s true —and there’s no second peak — that would be fantastic news…. If there’s a second peak that could be as bad if not worse. COVID-19 could come back in the Fall only to finish off in the spring of 2021 when we have a vaccine. That’s a harsh but not unrealistic scenario.