HOW IS COVID-19 DIFFERENT FOR CHILDREN?

This article was originally published on 29 June 2021 Given information is constantly changing, we have updated it, and will continue to do so as more information becomes available.

Brief Overview of COVID-19

When it started

Towards the end of 2019, there were reports of a strange, new infection in Wuhan, China. Infection control was slow to respond, and the virus that was causing this fatal disease rapidly spread throughout the world. Eventually named as SARS-CoV-2 (COVID-19 infection), it created a pandemic that quickly disrupted daily activities and affected hundreds of lives across many countries.

By January 2020, around 20 children from the province of Zhejiang were positive for the disease. A month later, reports showed that children comprised only 2% of the total number of cases in China. Interestingly, at that time, children who turned out positive did not have any comorbidities or other diseases, while most adults who tested positive had comorbidities.

COVID-19 as a disease

COVID-19 is an infectious disease that usually presents with fever, cough, colds, sore throat and difficulty breathing. Some adults and children may also experience a loss of taste or smell, stomach upset, body weakness and headache. However, most children who test positive for COVID-19 either present with mild or no symptoms at all.

COVID-19 in Children

Risk factors for COVID-19

While most cases of COVID-19 in children are mild or even asymptomatic, there are certain situations where children have a higher probability of becoming infected. Some conditions that place certain children at risk for COVID-19 include obesity, diabetes, asthma and other chronic lung diseases, congenital heart disease, an impaired immune system (immunosuppression due to a medical condition or due to certain medications), neurodevelopmental disorders, sickle cell disease, chronic kidney disease, and other genetic or metabolic conditions.

Symptoms of COVID-19

COVID-19 has some symptoms that are similar to the common flu and other respiratory infections. These include cough, cold, a sore throat, fever, body aches, and headache. Sometimes, difficulty breathing, fatigue, diarrhea, nausea, and vomiting may be present. Notable symptoms that could point to a COVID-19 infection are a new loss of either smell or taste.

How is COVID-19 diagnosed in children?

Doctors will take into consideration the presence of signs and symptoms, any possible contact with a confirmed COVID-19 case, and any other prevalent illnesses during that particular season or in that area.

The main diagnostic method for COVID-19 is through an RT-PCR test. This has the highest accuracy among other tests. It uses respiratory secretions, which are usually collected through sterile swabs placed at the back of the nose or the throat. The test checks for the genetic material of the virus (called RNA) in the specimen and amplifies any amount that is available in order to properly detect the virus.

Alternative tests include the antigen and antibody tests. The antigen test uses a nasal and/or throat swab and has the advantage of a quicker result than the RT-PCR test. The serologic antibody test, not as widely recommended as the first two, is used to determine whether your child was previously diagnosed with COVID-19. The antibody test can turn positive a minimum of two weeks after symptoms start.

According to the American Academy of Pediatrics, once COVID-19 is suspected in a child, immediate testing is recommended to prevent any possible further exposure to other children and adults. Negative test results should be repeated within 5 to 7 days from the last exposure to a positive case of COVID-19.

Other tests that help support a diagnosis of COVID-19 infection include the following:

• a complete blood count (usually showing a low white blood count or platelet count)
• markers of inflammation, such as C reactive protein (CRP) and procalcitonin
• lactate dehydrogenase (LDH) levels
• Chest radiograph
• Chest CT scan

How are children with COVID-19 treated?

The mainstay of therapy is supportive treatment. Children with COVID-19 should have enough fluid intake and an adequate amount of calories per day, and oxygen supplementation when it’s needed. If doctors suspect that there is an ongoing bacterial infection alongside COVID-19, a child may also be started on antibiotics.

The main goal of treatment is to prevent the disease from getting worse; this condition is called “acute respiratory distress syndrome”.

How COVID-19 Affects Children Versus Adults

Similarities with adults

COVID-19 has been defined as an infection due to the SARS-CoV-2 virus, a novel type of coronavirus. While typical symptoms are respiratory in nature (cough, cold, fever), some patients may not have any symptoms at all. Most of the characteristics of this infection are similar across children and adults.

Children and adults who test positive for COVID-19 were seen to have the same amount of viruses (viral load) infecting them through their nasopharynx (the area at the back of the nose and throat). The virus stays in the body and multiplies for around 2 to 14 days (average of 6 days) and can easily spread to others afterwards. Even if a child may have minimal to no symptoms, studies show that they still have a similar viral load to children with worse symptoms and in infected adults.

Like adults, children who have underlying medical conditions are at risk for severe symptoms. Infants less than 1 year old are more likely to develop a severe infection as well. Severe symptoms include respiratory failure, inflammation of the heart (myocarditis), inadequate blood flow across the body (shock), problems with blood clotting (coagulopathy), inadequate blood flow to the kidneys (acute renal failure) and multi-organ system failure.

A severe version of COVID-19 infection is called multisystem inflammatory syndrome, seen in both adults (MIS-A) and children (MIS-C). In children, MIS-C symptoms include a weak- or ill-looking child with high grade fever, dizziness or lightheadedness, vomiting episodes, rashes, abdominal pain, or diarrhea. MIS-C can affect the heart, brain, lungs, intestines, kidneys, blood, or the skin.

Differences with adults

1. Children have a lower risk of infection

Tracing the origins of the pandemic, adults were more likely exposed to areas where the virus started to develop and spread. There were less children roaming around hospitals and treatment centers. They were less exposed to the main sources of the infection, as well as areas for transmission.

Some studies have found a link between the risk of infection and a certain type of receptor found in the nose and throat. The angiotensin-converting enzyme 2, or ACE2 receptor, is a protein found on the surface of human cells. It’s the protein that SARS-CoV-2 uses to gain access into cells to replicate inside our bodies. Conditions such as diabetes, hypertension and coronary heart disease may increase the number of ACE2 receptors in the body. Adults are more prone to develop these diseases than children; having more ACE2 receptors may be linked to a higher chance of getting infected.

The immune system of a child has more naive T cells — these cells have not been exposed to other infections yet, so they may be “trained” to target new infections such as the SARS-CoV-2 virus. In this sense, it can be deduced that children can mobilize their immune system to easily target SARS-CoV-2, a new type of virus, as compared to adults whose T cells have already been more exposed to other infections throughout the years.

Children need to build their immune system as they grow older; they have a more active immune system that is constantly being exposed to seasonal viruses such as the flu. These perennial viruses have some similarities to the common cold in terms of structure. This leads to the concept of “crossover immunity”, which helps children fight off the virus more readily than adults can.

2. Children have milder or less symptoms

Children who do get infected mostly have mild to no symptoms. Most newborns who test positive usually get infected from respiratory secretions during delivery. However, most babies don’t have symptoms and are unlikely to need respiratory support, as compared to adults. There are some theories and observations as to why this happens.

Adults have accumulated inflammation in their bodies due to their lifestyle and environmental exposure. More inflammation leads to damage in certain areas of the body, such as the lining of blood vessels. This also affects how their immune system functions, leading to a less optimal response to the COVID-19 infection as compared to children.

Even the chronic effects of an unhealthy diet affect the body’s response to COVID-19. Some studies show that adults with low Vitamin D levels lead to worse symptoms. There is a higher chance of blood clots in patients with low Vitamin D levels; this event is noticeably one of the clinical manifestations in COVID-19 cases as well. Children, on the other hand, are more likely to be provided a complete set of nutrients due to guidance from parents and the community. Nevertheless, because of malnutrition issues like obesity and improper eating habits, there is an increasing rate of children with low vitamin D levels in industrialized countries.

Because children have mild to no symptoms, the rate of hospitalization is lower as compared to adults (2.5% versus 16.6%). Children with severe symptoms are usually those who are admitted to a hospital for further management.

3. Children have a lower mortality

Because children are less likely to get infected and are less likely to have serious symptoms, there are fewer deaths as compared to adults. According to the CDC, there were only <0.1% of deaths in children who tested positive, as compared to 5% of deaths in adults with the disease.

How is COVID-19 Managed in Children?

For children who have minimal to mild symptoms, isolation at home is recommended, with a dedicated set of food utensils, linen, towels, and bathroom. All frequently used surfaces, such as tables, switches, and doorknobs, should be regularly cleaned with household cleaning wipes or sprays, or soap and water if possible. Regularly wash hands with soap and water throughout the day.

It’s important to monitor your child’s symptoms and overall well-being. If their symptoms get worse, it’s best to seek medical attention.

As of writing, the Food and Drug Administration has approved sotrovimab for COVID-19 symptomatic and positive children aged 12 weighing 88 pounds or higher, or children at high risk for severe COVID-19 infection. Evusheld (tixagevimab & cilgavimab) is another monoclonal antibody medication given as pre-exposure prophylaxis. This means that Evusheld is given to children who have not been infected with COVID-19 yet as a precautionary measure.

Another method of prophylaxis is vaccination. The Pfizer-BioNTech COVID-19 vaccine is available to children aged 5 and older. The current primary series is a set of three doses. Immunocompromised children may be given an additional dose, depending on a case-to-case basis. While the vaccine helps prevent the spread of COVID-19, it doesn’t provide 100% protection from getting the infection. What it does is reduce symptoms significantly, sometimes to the point of having no symptoms at all. However, children who test positive for COVID-19 can still spread the virus, even if they are already vaccinated.  Additionally, Sinopharm’s vaccine is also approved in some countries for children aged 3 and older.

As of this writing, the SARS-CoV-2 virus has had a number of mutations, with the most common being the alpha, delta, and omicron variants in children. Recent cases have been increasing as the omicron variant in particular has a high rate of transmission from infected people. However, most children have mild symptoms and rarely need intensive care. The most common symptoms are fever, cough, sore throat, loss of sense of smell or taste, and other gastrointestinal symptoms.

Summary

The burden of COVID-19 in terms of health is much less on children in comparison to adults. Children have a more responsive and adaptive immune system that helps fight off the infection. This leads to less risk for infection, a smaller number of cases, less severe symptoms, and a lower risk for death. Nevertheless, since children can still spread the virus to other people, proper safety measures and guidelines should still be practiced for children, when applicable.

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Sources:

• https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/
• MAY 2020 study - https://journals.lww.com/pidj/fulltext/2020/05000/coronavirus_infections_in_children_including.1.aspx
• https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/symptoms.html
• https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html
• https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html
• https://www.who.int/emergencies/diseases/novel-coronavirus-2019/media-resources/science-in-5/episode-22---children-covid-19
• https://www.healthline.com/health-news/kids-are-half-as-likely-get-covid-19-as-adults-heres-what-we-know
• https://adc.bmj.com/content/106/5/429
• https://www.nature.com/articles/d41586-020-03496-7
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• https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928
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• https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/covid_inflammatory_condition.aspx
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