Let’s Recognize Childhood COVID as the Crisis It Is

COVID-19 demonstrates that infectious diseases needn’t be extraordinarily lethal to be devastating to public health. With some exception, in any given child, the most probable outcome of COVID-19 is, thankfully, a complete and uncomplicated recovery. But the calculus of risk changes drastically when considered from a public health lens, especially with considerations unique to children. For example, ethical considerations are more complex since children typically lack decision-making capacity, thus paternalism in their care is unavoidable (informed permission). This situation generally favors conservative approaches to their risk so they can grow to the stage of life where they do have capacity.

Deaths in childhood represent an extremely premature loss of life, and for that reason have larger effects on public health metrics, such as disability-adjusted life years. Ensuring the health of children is also critical for health equity. These are anodyne assertions: they amount to the simple truth that children are deserving of protection.

Let’s use influenza — another respiratory RNA virus of eminent public health importance, which has a mechanism of spread similar to SARS-CoV-2 — as a point of comparison. From 1999 to 2019, influenza was the eighth leading cause of death in children, yet this season, one pediatric flu death has been documented. This is likely due to aggressive non-pharmaceutical interventions (NPIs). Yet, in the same 2020-2021 season, the American Academy of Pediatrics reports (as of early June) 327 U.S. deaths in children, and the CDC reports 452 due to COVID-19 (both are underestimates, as these data are incomplete). COVID-19, in approximately 1 year, killed twice as many children as influenza does most years, and hundreds more in the same interval of time, despite painstaking efforts to prevent infection. This easily makes COVID-19 a leading cause of death in children.

Some have drawn distinctions between hospitalization with and hospitalization from COVID-19, which has merit: cases in children are usually milder or asymptomatic and they are screened within the hospital, so some cases certainly reflect incidental findings. Two such examinations have noted that nearly half of these pediatric hospitalizations were unrelated to COVID-19; we should be cautious about accepting the generalizability of these reports. But, for the sake of argument, applied to the entire U.S., that still amounts to approximately 100,000 pediatric hospitalizations caused by COVID-19 over the span of slightly more than a year, based on statistics generalized to the CDC estimates, or at least a minimum of 20,000, based on COVID-NET data. All estimates far exceed the number of hospitalizations during the pre-vaccine period for several vaccine-preventable diseases on the childhood vaccination schedule.

We must also consider multisystem inflammatory syndrome in children (MIS-C), a post-COVID-19 syndrome of the pediatric population, with a far greater risk of morbidity and mortality, including — perhaps most ominously — heart dysfunction. Disquietingly, the antecedent infections that result in MIS-C are frequently asymptomatic and the condition presents suddenly 4 to 6 weeks later. Of the documented cases in the U.S., approximately 1% have been fatal.

Post-acute sequelae of COVID-19 (PASC), commonly known as “long COVID,” is also a risk. There is wide variation in the estimated frequency of pediatric PASC, with some studies even noting as high as 42% of cases (though this figure is likely an overestimate). We can use the conservative value of 1.8%: using CDC’s estimates of infections, this would correspond to 480,000 U.S. children who face symptoms lasting longer than 56 days. Further epidemiological data will clarify the significance of PASC as a pediatric health problem, but we do note that clinics have been opened specifically to treat the condition, suggesting the burden is significant.

With the staggering fatalities reported in the pandemic, 400 pediatric deaths may seem paltry in comparison to the catastrophic deaths within nursing homes and ICUs. But consider: if COVID-19 affected only children with these statistics — 400 deaths, 20,000 to 100,000 hospitalizations, an insidious hyperinflammatory syndrome with significant potential for death and disability, and persistent symptoms after apparent recovery — would we ever regard pediatric COVID-19 with our current insouciance?

As we stated at the outset, COVID-19 is indeed much worse for many groups than it is for children — but the impact on the pediatric population is significant not only in their social and emotional wellbeing, but their physical health as well. Today, children are not supposed to die, and the loss of a child can be especially shattering in part because it isn’t supposed to happen. What does it say about us that when faced with one of the biggest modern threats to their safety, we are so willing to be complacent?

Children will benefit from the vaccination of adults through herd effects, and insofar as adults are the principal demographic at greatest risk for COVID-19, vaccination should be prioritized accordingly. However, as vaccine uptake increases, the burden of disease shifts to those who are unvaccinated. Though vaccination will reduce the total number of cases, the shift in cases to children raises some complex questions. The viral load in children, even asymptomatic, can be quite substantial, and thus it is probable that as vaccine uptake increases in adults, children may become the main vectors. Children should be vaccinated for their own protection, but there are also likely broader public health benefits because they comprise 23.6% of the U.S. population.

As we discuss vaccination of our children, we cannot ignore health equity — but it is a false dichotomy that we must choose between children or the devastated world. We can do both. Further, there is no proof that limiting U.S. vaccination will increase vaccination elsewhere, given distribution hurdles beyond the scope downstream of U.S. policy (though this should not be taken to undermine international aid, which is imperative).

The risks are modifiable. A seasonal decline in COVID-19 during the summer is likely and we can capitalize on this to ensure a safe return to school. FDA emergency use authorization (EUA) is a rigorous and appropriate pathway for delivering vaccination to children to quell this threat. All adolescents ages 12 and up without medical contraindication should receive the COVID-19 vaccine as soon as possible. It is virtually unheard of for an adverse event from vaccination to arise more than 2 months after vaccination, and especially implausible with current vaccine technologies. The known and potential benefits of vaccinating children far outweigh the known risks. As we await the conclusion of the age de-escalation, we want to emphasize that it is incumbent upon us to protect children with NPIs and cocooning as the circumstance requires. We all want a return to normalcy, but it is not fair to do it at the expense of children’s safety. We can prevent immeasurable suffering if only we treat pediatric COVID-19 with commensurate gravity.

Edward Nirenberg is a COVID-19 and medicine blogger. Risa Hoshino, MD, is a board-certified pediatrician working in public health with a focus on school health, vaccine education, and immigrant health in New York City.

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