What parents need to know about kids in the summer of COVID-19

As states reopen, the coming
months bring the prospect of gatherings at pools, playgrounds and even
amusement parks. But in this summer of COVID-19, many parents are left wondering
what their kids can safely do. 

There isn’t a satisfactory
answer, because there’s still so much unknown about the coronavirus in regards
to children. While studies from China to Italy to the United States have reported
fewer confirmed cases of COVID-19 in children than adults and fewer seriously
ill children than adults, recent reports of a dangerous inflammatory condition (SN: 5/12/20)
illustrate that harms may still emerge.

And
concerns about COVID-19 extend beyond kids to their family members and other
contacts. If children easily spread the coronavirus between each other and bring
it home, they could put relatives at risk and perhaps ignite local outbreaks. At
this point, it’s “still unclear whether they contribute significantly to
transmission,” says Aubree Gordon, an
epidemiologist at the University of Michigan in Ann Arbor. “But they well may.”

Scientists don’t have a full
understanding of COVID-19 and children in part because they don’t have a lot of
data from places well suited to provide it, such as schools and day care
centers. With the pandemic keeping most kids from engaging with their
communities as they usually would, we’re left with an incomplete picture of how
readily children spread the virus.

But there are studies and reports
that have provided clues. This research provides a preliminary snapshot of what
the illness means for kids and what we know so far about their role in
spreading the infection.

Children are getting sick less often than adults

Much remains unknown about
why COVID-19 can be devastating to some healthy adults and children. But at
this stage, studies report relatively few cases of severe illness in kids.
“Children overall are doing much better and are less sick than adults,” says
Samuel Dominguez, a pediatric infectious disease specialist at Children’s
Hospital Colorado in Aurora.

A study from the U.S.
Centers for Disease Control and Prevention found that of close to 150,000
confirmed cases of COVID-19 as of April 2, just over 2,500, or 1.7 percent,
occurred in those under the age of 18; that group of children accounts for 22
percent of the U.S. population. The researchers had hospitalization information
for 745 of the children’s cases: 147 had been admitted to hospitals, with 15 in intensive care. Three children died, the researchers
reported in the April 10 Morbidity and
Mortality Weekly Report
. CDC data as of May 23 continues to show a much higher hospitalization rate for COVID-19 in adults than in children.

But word of a dangerous,
excessive immune response in some children that may be linked to a SARS-CoV-2
infection renewed fears. Eight children with persistent fever and
gastrointestinal symptoms required intensive care in London in mid-April. The
children, one of whom died, had tested positive for antibodies to the coronavirus, the study authors reported online May 7 in the Lancet. A positive antibody test is evidence of a prior infection (SN: 4/28/20).
Days later, also in the Lancet, doctors
from the hard-hit Bergamo province in Italy reported similar symptoms in 10
children, eight of whom had evidence of antibodies to the coronavirus.

As of June 1, New York state’s
Department of Health is investigating 189 cases of the inflammatory syndrome. Washington, D.C., and a
growing number of states, including Wisconsin, Louisiana and Florida, also have
reported cases. The CDC has released a health alert and case definition for the syndrome, which they’ve named multisystem
inflammatory syndrome in children, or MIS-C.

The syndrome shares some
symptoms with Kawasaki disease, which mainly strikes children younger than 5 and
is marked by high fevers, inflammation and sometimes poor heart function. But
multisystem inflammatory syndrome is also hitting older children and teens and
frequently includes gastrointestinal symptoms not commonly seen with Kawasaki
disease. 

Researchers theorize that
the syndrome is an immune response linked to an infection with SARS-CoV-2,
showing up around four weeks later, says Jeffrey Burns, a pediatric critical
care specialist at Boston Children’s Hospital. Children becoming critically ill
from the syndrome at this point “remains very infrequent,”
he says.

It’s not clear why children don’t tend to get
as ill with COVID-19 as adults. “I don’t know if that is really a biological or
immunological phenomenon or if it’s an exposure phenomenon,” says Dominguez,
tied to how
quickly schools were closed
and children were isolated due to
social distancing. “Did we just spare them because they weren’t exposed?”

It’s not clear how much kids contribute to spread

In January, a 9-year-old on a
ski holiday in the French Alps with his family was exposed to a traveler with
COVID-19. His experience may provide the best-case scenario of what can happen
when a child is infected.

After contracting the coronavirus,
the child experienced mild symptoms. And despite attending three different
schools while ill, he did not transmit the virus to any of the 55 school contacts tested, researchers
reported April 11 in Clinical Infectious
Diseases
. Nor did his two siblings become infected. Yet influenza was
spreading between children at the schools and among the siblings at the very
same time.

One of the rationales behind
the quick closure of schools in the face of COVID-19 was drawn from past
experience with children and influenza. Children — particularly young children
— are considered the main drivers of flu transmission within communities, and
shutting schools has curtailed the spread of the flu during past epidemics and
pandemics.

But the role that children
play in spreading SARS-CoV-2 is less apparent. The vacationing schoolboy and
his classmates may have just been lucky, but there’s other early evidence that
children may not be as important to the spread of the coronavirus as they are
to influenza.

A peek into schools in
Australia early in the pandemic suggests that the virus may not spread wildly
among students. In New South Wales, the Australian state that includes Sydney,
18 people from 15 schools — nine students and nine staff — were confirmed with COVID-19
from March 5 through April 3. Even though 735 students and 128 staff were in
close contact with the initial 18, only two students appeared to have contracted the coronavirus at school from those first cases.

Ireland reported its first
case of COVID-19 — a student who had been to Northern Italy — at the beginning of
March; schools closed at the end of the day on March 12. In that time, three
students (one without symptoms) and three adult staff with COVID-19 were in contact with 924 children and 101 adults at schools. None of the contacts become
infected, researchers report May 28 in Eurosurveillance.

Sweden has kept many schools
open during the pandemic, but the country’s Public Health Agency hasn’t
released data on how students and teachers have fared. Meanwhile, in Israel,
some recently reopened schools have shut again after cases of COVID-19 were
reported among some staff and students.

Within the home, studies
have suggested adults rather than children are more often the first to get sick
in a family. But kids may not be any less susceptible to infection, according
to a study in Shenzhen, China of 391 COVID-19 cases and 1,286 close contacts. Children
under the age of 10 were as likely to be infected as adults, the researchers reported April 27 in the Lancet Infectious Diseases.

One sticking point in
understanding the role children play in the spread of SARS-CoV-2 is that
researchers don’t know the extent to which kids can be infected and asymptomatic
but still pass the virus along. Studies of adults have found that they can
spread the virus if they never have symptoms (SN: 3/13/2020) and before symptoms appear (SN: 4/15/20).

Without widespread testing,
it’s hard to pin down the number of children with asymptomatic cases of
COVID-19. A few studies have provided estimates. For example, out of 728
confirmed cases in children in China, 94 did not have symptoms, a total of 12.9 percent, according to a study in the
June Pediatrics. A smaller study
found a higher percentage: Among 36 children up to the age of 16 who were
confirmed with the infection as of March 1 in Zhejiang, China, 10 were asymptomatic, or 28 percent, researchers reported in the June 1 Lancet Infectious Diseases. It’s also
not clear yet whether asymptomatic kids readily infect others.

It remains possible that
children haven’t distinguished themselves as major transmitters of SARS-CoV-2
up to now because they haven’t been interacting as they usually would at schools,
day cares and playgrounds. “Certainly
children are major spreaders of other kinds of viruses,” says infectious disease pediatrician and vaccine researcher
Kathryn Edwards of Vanderbilt University School of Medicine in Nashville. “So that’s what’s so curious.”

Closed Arlington playground
Playgrounds like this one in Virginia closed in an attempt to prevent the spread of COVID-19. As states begin to reopen playgrounds, pools and other recreational areas, it remains to be seen whether gatherings of kids will lead to an uptick of cases.E. Otwell

What happens over the summer may fill in some blanks

Countries around the world
have begun to reopen some of their schools, with modifications such as smaller
class sizes, socially distant seating and frequent handwashing breaks. The
experiences of school systems abroad may provide more data as U.S. officials consider
plans to reopen schools here.

Those plans will proceed without a
vaccine. Promising candidates will need to be studied in children to make sure
they are safe and effective for younger ages. Current vaccine
trials
are being conducted in adults (SN: 5/20/20), although the University of
Oxford has announced plans to begin testing their COVID-19 vaccine in children.

That leaves officials as well as parents waiting for more research, testing and contact tracing (SN: 4/29/20) to reveal more about the virus’ spread and its impact on children. Until then, it will remain challenging to decide what’s safe for kids during the summer of COVID-19.

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