While at low-risk for severe COVID-19 disease course, children face risks of mental, social, emotional, and physical impact from the pandemic. Is healthcare ready to respond?
It would be remiss to assume children will emerge from the COVID-19 pandemic wholly unscathed.
Of course, for everyone, this past year has largely been a period of stress, change, upheaval, and uncertainty. Lockdowns have forced families to adapt to new circumstances, social interaction has shifted to virtual settings, and the virus itself has placed physical burdens for many, especially those with comorbidities and chronic conditions.
Understandably and appropriately, mainstream conversations in healthcare have underscored the protection and treatment of high-risk individuals. Other central discussions have included prioritization of individuals during vaccine rollout, the mental health toll of the pandemic, and — in the pediatric space — “getting the kids back to school.”
Conventional thought and healthcare heuristics have labeled “low-risk” individuals in COVID-19 severity.
“Hospitalization rates in children are significantly lower than hospitalization rates in adults with COVID-19, suggesting that children may have less severe illness from COVID-19 compared to adults,” notes the US Centers for Disease Control and Prevention (CDC), before qualifying that many unknowns persist for healthcare experts and providers.
If this is indeed the case, as the current and available evidence suggests, this should not warrant complacency among healthcare professionals and relatives.
In fact, conversations surrounding the effects of the pandemic should continuously acknowledge that pediatric populations may suffer from risks beyond a virus—risks that older generations may be almost completely immune to.
And the consequences of these risks may have lifelong effects.
The pandemic can be assessed as a trauma-inducing event, and the wellbeing of children in light of that context cannot be understated.
With over 500,000 and counting COVID-related deaths in the US, swaths of children are subjected to exposures and conversations surrounding illness and mortality.
“The grieving process is real for these children,” Sara Goza, MD, former president of the American Academy of Pediatricians, told HCPLive®. “And they don’t understand it.”
Even more, Goza emphasized, children can internalize the stresses and emotions of their parents, who may be experiencing illness and job insecurity, among many other personal hardships.
In addition to stress, negative emotions such as depression and anxiety are of particular concern. A systematic review published in late 2020 found that, compared to adults, children and adolescents are more likely to experience high rates of depression and anxiety during and following mandated isolation and social distancing measures.
The study highlighted that social isolation and loneliness increased risk of depression and possibly anxiety. Even more, there was a stronger correlation between duration of loneliness—as opposed to intensity of loneliness—and mental health symptoms.
“There have been real impacts on anxiety and depression and, in some kids, trauma related to this,” R. Neal Davis, MD, a pediatrician affiliated with Intermountain Healthcare, told HCPLive®. “I’m not saying it’s all kids that are impacted in that way. But it is a very significant group and a very significant conversation.”
Goza and Davis both expressed concern for the state of pediatric mental health on a large scale, adding that it’s not currently public health conversation on the scale of other effects brought on by COVID-19.
What’s more—if experienced trauma was not enough of a concern for parents—the decline in socialization has strongly disadvantaged younger children in highly critical stages of social learning.
The pandemic has brought on a change in behavioral norms, which have largely affected the way children, especially toddlers, learn socialization and emotional skills, Goza explained. She described from her personal practice how her patients, especially 2-3 year-old children, are failing to communicate and talk as extensively as they should.
There has been a noticeable deterioration in communicative abilities, especially with those in their own age group.
“We are seeing a lot of the behavioral and socio-emotional needs of those children that we will be dealing with for a long time to come,” she said.
She described this observation as an “unintended consequence” of the lockdowns, which had not previously been predicted.
A report published by the Urban Institute and Robert Wood Johnson Foundation highlighted the delayed and forgone health care visits for children during the pandemic.
The survey findings from 1254 participants indicated that 15.6% of parents reported delaying or cancelling multiple types of care for their children during COVID-19, which included routine care, routine checkups and screenings, general doctor and specialist visits, and immunizations.
Furthermore, parents with lower family incomes (defined as <250% of the federal poverty level) were more likely to delay or miss out on various types of healthcare—as compared with parents with higher incomes.
Suffice it to say, many children have been unable to receive their routine care and screening critical to their growth.
Even though this disruption in healthcare has certainly been felt across all age populations, this decline in pediatric care over the past year cannot be overstated.
“These parents reported it worsened their children’s health conditions (18.5%), limited their children’s abilities to go to school or day care or do school-work (15.6%) or do other daily activities (14.5%), or caused at least one of these consequences (27.7%),” the investigators wrote.
“Among parents who only delayed or did not get children’s dental care, we find very few reported one or more of these adverse consequences, suggesting the type of care missed matters.”
When it comes to physical health of children during the pandemic, missed or inconsistent appointments are not the only issues that matter, especially for pediatricians.
Looming in the shadows is a newly discovered condition called multisystem inflammatory syndrome in children (MIS-C), a condition defined by the inflammation of various body parts, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.
Evidence has linked MIS-C with recent infection with the virus that causes COVID-19. Many children with the syndrome had previously been infected with SARS-COV-2, even if their infection course was asymptomatic.
Per the CDC, symptoms associated with the multisystem inflammatory syndrome may include fever, abdominal, pain, vomiting, diarrhea, neck pain, rash, bloodshot eyes, or fatigue. Children may experience severe pain and symptoms, although many do end up recovering from it.
Goza and Davis stressed incredible concern over this syndrome, especially considering the lack of sufficient evidence to show which children (and why) go on to develop MIS-C.
They even indicated experience with the syndrome within their own practices.
At the time of writing, well more than 2000 children in the US had met the case definition of MIS-C. Another 30 had died from it.
All in all, the biggest concern is what’s still unknown: its long-term impacts are yet to be ascertained, and the precise nature of the syndrome is the subject of ongoing studies.
“This is something very important to keep on the radar,” urged Davis.
Children are an impressionable population that present unique vulnerabilities, many of which cannot simply be dismissed.
Conversations this past year have focused on certain aspects of children’s wellbeing, but the healthcare and lay community cannot lose any urgency in approaching and ensuring pediatric health in a holistic manner.
That is to say, healthcare providers and caretakers must remain vigilant of the mental, emotional, social, and physical toll of the pandemic on pediatric populations. They may not have the exact risks and comorbidities as the older and elderly populations, but their vulnerabilities are just as real and worrisome.
Working with children during a pandemic can be just as complex and multi-faceted, to which Goza and Davis can attest.
Both pediatricians described their experiences talking with their patients about the pandemic; gauging their knowledge; their social, emotional, mental, and physical needs; alleviating fears; and ensuring they and their guardians have open, honest, and informative conversations about risks and challenges in children.
To complicate matters, healthcare professionals should be attuned to the social disparities within the pediatric populations—issues like food insecurity and poverty levels, which can further exacerbate these baseline risks among children.
In short, over the past 12 months, a child’s world has drastically changed. It has perhaps become increasingly dangerous, more harsh, more grim. That is a reality that cannot be ignored.
Nevertheless, one cannot totally disregard that eternal flame that shines in all children, regardless of risk, peril, and change.
“During this past year, I have learned how important to it is to remind parents and society of the fundamental resilience of children,” Davis said. “Children are designed to succeed, even in hard times."
“And frankly, if we look for those opportunities to help them thrive amidst this difficult time, we can learn a lot from them that can help us find a path forward as well.”