“I sent a letter to my father, on the way I dropped it.
Someone came and picked it up and put it in my pocket!”
Kindergarten. Hopscotch. Basketball. Playgrounds. Then flashy yellow “caution” tapes forbidding lessons and memories of a lifetime. Along with the title of a ‘Killer’, the COVID-19 is rightfully synonymous to a ‘Thief’. Stealing the phenomena called ‘childhood’ for age groups across the world. All hell broke loose in December 2019 when Wuhan, China reported of an unexpected surge of cases leading to this millennium’s pandemic. Severe-Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV2) is every parent, guardian and child’s new monster. In a population of 1.967bn children aged 0-14 years 1 a range of 1.2%-5% have fallen prey to this “monster”. 2
“But kids don’t get it” “Kids don’t die..”
Studies outlining the clinical picture of COVID-19 in children are numbered, and still in progress. That said, parents can take a sigh of relief with one fact: The disease runs milder in babies and children. Children tend to have milder infections, with a substantial portion being asymptomatic. This mean the prevalence of COVID-19 can be hard to finalise and hence the risk can get underestimated.
For reasons obvious to age, emotional and financial dependency the two common factors leading to the infection are children coming in close contact with an affected family member or residing in an area with a high population of cases.
The presenting symptoms have a variance but most of them show dry cough (approximately 50%), unremittent high fever (40%-50%) sore throat (25%), shortness of breath (13%), diarrhea (13%), rash, with some experiencing malaise or fatigue as presenting features.2 Though less likely to be hospitalized, however on May 14th 2020, the United States Centers for Disease Control and Prevention (CDC) released a health advisory reporting a multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. 3
Doctors in the US and UK have discovered but in a small population of 2 to 15 years old a condition called pediatric inflammatory multisystem syndrome, or PIMS. A hyperinflammatory disease, where the children present with symptoms resembling Kawasaki’s disease which include prolonged fever, pink eyes, rashes, swollen hands and feet and abdominal pain. In very rare instances, child have presented with symptoms of shock, meaning that their blood pressure was very low. The condition occurs as a result of delayed immune response of the body to the virus’ attack. However, there is comfort in knowing that this incredibly rare condition when detected early and treated appropriately, children recover well. 4
But the irony – Why are kids less susceptible to this virus?
Though all under study, here are a few possible explanations:
1. Angiotensin-Converting Enzyme 2 (ACE2) activity. It is a type I membrane protein expressed in many organs such as lungs, heart, intestine and kidneys where it is physiologically involved in the maturation of angiotensin II enzyme (AngII). Known as the doorway, ACE2 has been proven to be the receptor of SARS-CoV-2. 5 The evidences suggest that the decreased concentration of ACE2 receptors in lung pneumocytes or low levels of ACE2 gene expression in nasal passages of children may have a protective effect on severe clinical manifestations due to SARS-CoV-2 infection. 6
2. Interferon (IFN) is a cluster of glycoproteins, synthesized by the infected host cells as a result of an antiviral response to the body’s virus attack. Interferons have essential role as antiviral factors via two mechanisms:
(a) Stimulate production of antiviral effector proteins, inhibiting viral replication.
(b) They activate T-cell immunity to remove the virus.
An earlier stimulation of interferons in children and their minimal developed immune system may be the cause of increased protection against the wrath of SARS-COVID19. 7
3. Physiologic evolution of Thymus gland. This directly impacts immunity. An increase in the percentage of CD4 cells in children with a consistent decline of levels in adults. While percentage of CD8 cells is maintained or shows a slight increase in elderly. Several studies have established a higher number of CD4 and lower CD8 cells in children than adults. Being more active in childhood than adulthood, the atrophy of the thymus gland is associated with a lower production of T-lymphocytes. 7
Meanwhile, while this pandemic runs its course, it is our faithful duty to be vigilant for the sake of our immediate children and the future generations. For starters, we need to assure that the child keeps up with his/her otherwise routine immunization. This still acts as their number one bet against all vaccine-preventable diseases around the world. Keeping infants, children, and youth on time for their primary immunizations and booster doses is vitally important during this pandemic, because vaccine timing is based on complex disease epidemiology and immune responses. 2
Secondly, though sad but true the medical conditions other than COVID-19 are taking a back seat when it comes to going to the hospital. In cases of an emergency, families should not be discouraged for seeking medical care because of the scare of this pandemic.
Lastly, it has been agreed by both PHAC and the American Academy of Pediatrics (AAP) that masks covering the nose and mouth can be used by adults and by children over 2 years of age in community settings, for short periods, when physical distancing measures cannot be taken. It is the duty of the adults to stimulate logical reasoning in the child about the significance of keeping a good distance, respiratory etiquettes and regular handwashing.
Keeping the population in mind, understand their need to be physically active, their anxiety of being friend-less and their priorities of playtime vs Instagram. It is okay to discuss with your kid about “new germs in the air and surfaces, and that the scientists are still learning about it each day.” It will be the concentrated and combined efforts of the parents, politicians and professionals that will allow each class to graduate with flying colors, in the present and post-COVID19 world.
1. Population ages 0-14, total. https://data.worldbank.org/indicator/SP.POP.0014.TO.
2. Saux, N. L. (2020). Update on COVID-19 epidemiology and impact on medical care in children: April 2020. Canadian Pediatric Society
3. Hoang, A., Chorath, K., Moreira, A., Evans, M., Burmeister-Morton, F., Burmeister, F., Moreira, A. (2020). COVID-19 in 7780 pediatric patients: A systematic review. EClinicalMedicine, 24, 100433.
4. Canadian Pediatric Society
5. Midulla, F., Cristiani, L., & Mancino, E. (2020). Will children reveal their secret? The coronavirus dilemma. European Respiratory Journal, 55(6), 2001617. https://doi.org/10.1183/13993003.01617-2020
6. Mount Sinai Hospitals
7.Rehman, S., Majeed, T., Ansari, M. A., Ali, U., Sabit, H., & Al-Suhaimi, E. A. (2020). Current scenario of COVID-19 in pediatric age group and physiology of immune and thymus response. Saudi Journal of Biological Sciences.