Take It From a Pediatrician
Today I’m thrilled to present a guest essay written by my friend and California-based pediatrician, Jessica Hochman, MD. Jessica is one of the most caring, thoughtful, and smart physicians I know. She has her finger on the pulse of the evolving data around COVID-19 and elegantly applies her knowledge to the children and families she cares for every day.
Jessica also provides sane, evidence-based advice on her podcast “Ask Dr. Jessica.” I always learn so much from pediatricians and hope you enjoy what Jessica has to say about COVID-19 and kids!
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A pediatrician’s perspective
As the news unfolds that some states such as Oregon, New Jersey, Delaware and California are relaxing mask mandates, I’m noticing a wide spectrum of reactions from patients and their families. Many prefer to do everything possible to prevent contracting the virus, and favor continued restrictions, including masking. Other families are ambivalent; they would like to move forward beyond the pandemic, but they also want to do the “right thing.” Finally, I talk to families who are frustrated by the mask mandates, and are pivoting to homeschooling, changing school districts, and even moving out of state to places their children will not be required to wear a mask.
In my view, all of these feelings are understandable. We have all been affected in one way or another since the emergence of COVID-19, each of us impacted by our own lived experience, and our varying level of risk tolerance.
As COVID-19 restrictions relax, my approach to the inevitable “COVID-19 conversation” with families in my practice is as follows:
First, I share my genuine optimistic and evidence-based perspective to help assuage fear. Looking at the big picture, there has been significant progress. We have made so many positive advances since the novel coronavirus first appeared. There are widely available effective vaccines that protect people from getting severely sick from COVID-19. Furthermore, the current dominant Omicron variant strain has shown clear signs of burning out as the daily case numbers have begun to plummet. Compared with the original SARS-CoV-2 strain, the virus overall has become less virulent. While we cannot predict the future of COVID variants, the natural course of many pandemics with respiratory infections is that they settle into an endemic steady state in which they cause milder illness in their hosts and perhaps this is what is finally happening with SARS-CoV-2. Lastly, data show that the vast majority of children thankfully experience mild illness followed by a complete recovery from COVID-19.
Here are some my patients’ most common concerns at this point in the pandemic, followed by my response:
My child has had COVID. Will this provide him with lasting immunity from the infection?
Yes! There is, in fact, good evidence that after children recover from SARS-CoV-2, their immune system develops a robust immune response, and even greater when compared to adults. One study found a strong immune response in children even 1 year after infection.
My child is too young for the vaccine, should I worry about them?
For families awaiting vaccine approval for children under five years, there may be disappointment in the FDA’s decision to postpone vaccine authorization. While vaccines have been beneficial in preventing severe disease, it is critical to keep perspective. Even without vaccines, healthy young children with SARS-CoV-2 fare very well—better than vaccinated adults—with a death rate approaching 0%! There is also compelling data that vaccinated adults, living in a household with children, offer a protective "cocooning" effect for their unvaccinated children. Last, for children under age 5, infections with the Omicron variant have been associated with less severe outcomes than the Delta variant.
If my child gets COVID-19, will he end up in the hospital?
This is an understandable concern, especially in light of the recent increase in total child hospitalization numbers. The omicron variant resulted in a surge of cases, therefore increasing the total number of children hospitalized. But the good news is the hospitalization rate for children is still quite low, and trending even lower. In fact, young age is the strongest risk factor to protect against COVID-19 hospitalization (see chart below). This week, the CDC reported that, for under 18 years of age, there is a hospitalization rate of 2.4 for every 100,000. Even these statistics may be an overestimate, according to a Stanford study of universal COVID-19 testing for inpatients. This study found that roughly 45% of infected children were admitted for reasons unrelated to the virus. Even more reassuring, with the omicron variant, children present with milder symptoms and have shorter hospital stays, compared with the previous delta variant.
Should I worry my child will get Long COVID or MIS-C?
Many families are concerned that although children generally recover from an acute infection of covid, they may suffer from long COVID or a rare but serious condition called Multisystem Inflammatory Syndrome in Children (MIS-C).
Long COVID is defined as persistent symptoms following a COVID-19 infection, such as fatigue, loss of smell, loss of taste and respiratory symptoms, lasting over four weeks. With regard to long COVID and children, the biggest study to date, conducted in Denmark, showed that long COVID is not a major risk to children. This study looked at 37,000 kids, and found that 0.8% of children who were positive for SARS-CoV-2 had symptoms that persisted beyond four weeks. In most cases of long COVID, symptoms resolve within 1 to 5 months. In short, children may experience longer lasting effects from COVID, but this situation is relatively temporary and most always resolves.
As for MIS-C, this inflammatory condition appears to be an uncommon complication of the SARS-CoV-2 virus, affecting children and adolescents. There are effective treatments and most children who have MIS-C eventually get better. Furthermore, a recent study in France found that adolescents who received two doses of the COVID-19 mRNA vaccine had significant protection against MIS-C. While the overall risk of MIS-C is rare, vaccination brings that risk even lower.
Now to further discuss the trend towards relaxing mask policies:
The question emerges: As the coronavirus moves on a path towards endemicity, and in consideration of our COVID-19 progress, what is our path towards normalcy, including removing masking mandates?
A well-fitted high quality mask, worn properly and in the right circumstances, may offer protection. In real-world childhood settings, however, the benefits may not outweigh the risk. For example, my 11-year-old daughter, who attends a Los Angeles public elementary school, is required to run “the mile” outdoors while masked, even on hot days. My 2-year-old asthmatic niece is required to wear a mask outdoors at her preschool, despite having a medical exemption letter from her allergist. These two examples beg the question: Does the potential modest slowing of COVID-19 spread justify the inconvenience—even harm—that masking does to our children? “One size fits all” mask recommendations lack the nuance critical for good medicine and public health.
Many parents dutifully comply with children’s mask mandates because they believe “masks are harmless” and their children do not complain. I can relate, as my three young children wear their masks at school without complaint. But, I do believe the onus is on parents to ensure that children are gaining a net benefit, taking into consideration there is much more to good health than avoiding COVID-19. Although kids may not vocally complain, we do not yet know the full effect on children wearing masks for a sustained period of time. Masks create a physical barrier that may, in fact, impede our children’s development. There is great value in seeing faces and reading expressions of others. Masks potentially prevent children from forming important childhood connections, and may pose a risk to long term development.
As a pediatrician, I have treated hundreds of children with COVID-19, with symptoms similar to the common cold and flu. From my vantage point, the big difference in the last two years is that anxiety has become increasingly pervasive, with many people avoiding playdates, social gatherings, or camp. Perhaps worst of all, I’ve had to treat more children for clinical anxiety than ever before. Discussions with parents about their child’s psychological symptoms—racing thoughts, chest tightness, insomnia, depression, social anxiety, nail biting, relationship struggles, tantrums, obesity and even suicidal ideation—are more frequent topics of concern than ever before.
In conclusion, at this moment of the pandemic, it’s appropriate for each child and parent to make the best choice for the safety of their family based on the child and family’s unique medical vulnerabilities and risk tolerance. Based on my experience, the anxiety regarding COVID-19 as it affects our children is disproportionate to the actual threat to most children. It’s important for doctors like me to keep helping families mitigate their COVID-19 risk and also put it in perspective given the array of other health issues that kids face every day. I feel optimistic that the trend towards ending mask mandates represents an important step in the journey back towards a normal childhood experience.
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