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An Expert Explains: Covid-19 and your children

More children have been infected in the second wave than in the first. Amid concerns about new variants , children’s health, and mental well-being as schools stay shut, what should parents do or not do? If parents fall ill, what changes in the way they take care of small children? What do they do if the child falls ill?

We keep hearing of a third wave of Covid-19, and that children will be the most vulnerable. Is that a real fear?

Several experts have warned that the third wave is likely to affect more children, as Singapore has already been reporting. One can get immunity either after infection or through vaccination. More adults have been getting infected in both the first and second waves. Vaccination has been approved for use in adults. The absolute number of children affected in the second wave seems more than in the first wave, probably due to overall increased numbers and entire families getting affected.

Are any of the new variants more dangerous for children than for adults?

The new mutations, particularly the B.1.167 variant, have been reported to be affecting younger children in a few countries like Singapore. However, there is no official confirmation at this stage as to how many children have been affected by the new variant in Singapore.

The B.1.1.7 strain is 60% more fatal than the original strain. It is believed that since the immunity of children is better, they are not getting seriously sick even after this mutant virus attack.

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In general, are children at lower risk of contracting Covid-19 than adults? And among children, which age group is more vulnerable?

Children are just as susceptible as adults. However, children with Covid-19 are generally asymptomatic or have less severe manifestations. This may be attributed to a lower expression of specific receptors to which this virus binds to enter the host, and also their immune system.

A U-shaped curve of severity has been demonstrated in children, with infants under 1 year of age and adolescents (10–14 years of age) with a higher risk of developing severe Covid. Infants might be seriously ill. Older children might develop MIS-C (multi-system inflammatory syndrome) after 2-6 weeks of asymptomatic or symptomatic Covid-19 infection.

Are symptoms in children different from those in adults?

The most common symptoms are fever (63%) and cough (34%) followed by nausea or vomiting (20%) and diarrhoea (20%).

Similar to adults, the commonest clinical features are fever and cough; however, their frequency is much lower in children (60-100% in adults vs 40-60% in children). Most of the children have mild to moderate disease, and only 4% have a severe illness. On the other hand, features like shortness of breath, fall in oxygen levels, and sputum production are more frequently seen in adults. Like adults, gastrointestinal manifestations (diarrhoea, vomiting) are frequently seen in children and sometimes may be the sole manifestation of Covid-19 in children. Overall, respiratory symptoms followed by gastrointestinal symptoms are the predominant manifestations in children as well as adults.

Also, adults have a higher chance of having underlying comorbidity, which predisposes them to severe Covid illness. According to US CDC estimates, Covid-19 hospitalisation rates were 80 times higher among adults older than 85 years than among children between ages five to 17. Death rates for adults older than 85 years were 7,900 times higher than for children.

What should people do if they suspect their child is showing symptoms of Covid-19?

Children with documented or suspected Covid-19 and mild symptoms — fever, cough, pharyngitis — generally should be managed at home unless they have an underlying health problem like asthma, heart disease, diabetes, muscle dystrophies and refractory epilepsies. These may increase their risk of severe disease. Management at home is focused on prevention of transmission to others (i.e. isolation), monitoring for clinical deterioration, and supportive care. Treatment for mild cases is symptomatic.

Children at home should be monitored for the development of severe Covid illness. Manifestations include:

* Difficulty in breathing, grunting, inability to breastfeed

* Chest pain or pressure ( adolescents)

* Bluish discolouration of lips or face

* Cold, clammy, mottled skin, substantially reduced urine output

* New-onset confusion; difficulty in arousing

Besides, there should be regular communication with the doctor.

* Duration of isolation: For symptomatic patients: 10 days after symptom onset, plus at least 3 additional days without symptoms. For asymptomatic cases 10 days after positive test.

If a child is Covid-positive, does she need to be isolated if her parents are vaccinated, and if they are not?

If a child tests positive and their parents are negative, parents can continue to take care of the child. However, while caring for their child, parents should:

* Use a proper mask.

* Wear PPE, including gloves.

* Avoid leaving the child with her grandparents.

Families shouldn’t rush back into pre-pandemic life, even if both parents are fully immunised.

Can a pregnant woman pass on SARS-CoV-2 to her unborn child?

At this time, there is not enough evidence to determine whether the virus is transmitted from a mother to her baby during pregnancy, or the potential impact this may have on the baby. This is currently being investigated.

Pregnant women should continue to follow appropriate precautions, and seek medical care early if experiencing symptoms such as fever, cough or difficulty breathing.

What should parents with a very small child, who cannot be kept away from them, do if they catch the virus?

If you have Covid-19, you will not be able to hug your child or touch them in any way without putting them at risk. Younger children may find this very difficult to adjust. Even if you are sharing the same space, you can consider coming up with creative ways to communicate, just to liven up the atmosphere. Perhaps you can speak over the phone (with your child using one that you don’t use), make video calls, or send each other emails if you have devices that are not shared. Get a family member or friend to speak to them regularly over the phone.

According to the CDC, everyone at home who is above the age of 2 is able to remove the mask by themselves, and who does not have breathing issues, should be masked at all times if there is a Covid-19 patient at home. Surfaces should be disinfected frequently. A distance of at least six feet should be maintained between you and your child.

Is it safe for a Covid-positive mother to breastfeed?

At present, data is not sufficient to conclude transmission of Covid-19 through breastfeeding. In infants, the risk of infection is low, and the infection is typically mild or asymptomatic, while the consequences of not breastfeeding and separation between mother and child can be significant. At this point, it appears that Covid-19 in infants and children represents a much lower threat to survival and health than other infections that breastfeeding is protective against.

Based on available evidence, WHO recommendations on the initiation and continued breastfeeding of infants and young children also apply to mothers with suspected or confirmed Covid-19.

With schools shut down, what should parents do (or not do) to ensure the mental well-being of children?

During the pandemic, psychological problems like anxiety, depression, irritability, mood swings, inattention, and sleep disturbance are fairly common (79.4% as per a recent meta-analysis of 15 studies from 10 countries describing 22,996 children/adolescents) among quarantined children in several studies. Children with pre-existing behavioural problems like autism and attention deficit hyperactivity disorder have a high probability of worsening their behavioural symptoms.

Parents & young children

* Parents should devote time to provide younger children with undivided, positive attention and reassurance.

* Children need to be given fact-based information about Covid-19 with the help of presentations and video material provided by authorised organisations like WHO and UNICEF, or government resources tailor-made for children.

* Children’s exposure to news should be limited, and should be to fact-based content.

* Efforts should be made so that a consistent routine is followed by the child, with enough opportunities to play, read, rest and engage in physical activity.

Parents & adolescents

* This is the best time for parents to model the most important life skills i.e. coping with stress, coping with emotions, and problem-solving with their children.

* Adolescents are expected to have better knowledge about Covid 19 compared to young children. Therefore, communication has to be more open and non-directive.

* This is an opportunity for older children to learn responsibility, involvement, and collaboration. They can learn skills including cooking, managing money matters, first aid, organising their room, and contributing to managing chores .

* Excessive internet use related to Covid-19 should be avoided as it results in anxiety. Similarly, excessive and irresponsible use of social media or Internet gaming should be cautioned against.

* Taking up creative pursuits like art, music, dance and others can help manage mental health.

* Adolescence is a phase of enthusiasm and risk-taking, hence some may try not to follow guidelines. This has to be addressed assertively.

* It is advised to parents to take care of their own mental health needs.

Can Covid-19 cause developmental delays in children?

In a meta-analysis that included 9,335 children (0 to 19 years) from 31 countries with documented SARS-CoV-2, neurological symptoms were present in 12% of children. This is common in those who develop MIS-C. Only 2% of children developed life-threatening neurologic involvement like severe encephalopathy, stroke, central nervous system infection etc.

The struggles faced by children with special needs are diverse, including higher risk of SARS-CoV-2 infection, restricted access to healthcare facilities, limited capability to practise preventive measures along with increased rehabilitation needs due to interruption of schooling.

The concerns of these children and their caregivers should be resolved with appropriate solutions to accomplish an inclusive healthcare response to the global pandemic. Children with chronic neurodevelopmental disorders are a vulnerable population in this regard.

Should parents delay other vaccines for a child who is suffering from or has just recovered from Covid-19?

Routine immunisation can be continued two weeks after the child is asymptomatic (of Covid infection). If a child needs some higher medications such as high-dose steroids, which suppress the components of patient immunity, immunization needs to be deferred for three months after the medication has been stopped.

What should parents do to protect babies and small children who cannot wear masks?

The Indian Academy of Paediatrics recommends that masks need to be worn by all children above the age of 2 years. If a decision is made to use a face shield, it should cover the entire face, wrap around the sides of the face and extend to below the chin. Caution should be taken while wearing one to avoid injuries that could break it and harm the eyes or face.

You should never use a mask on a child under the age of 2. Avoid unnecessary public contact. Keep yourself, your baby, and any siblings at least 6 feet away from other people. If you cannot leave an infant or young child supervised at home and you must go out, keep the outing short.

* If you must take your baby out in public, cover the infant carrier (not the infant) with a blanket.

* Do not leave your child alone ever.

* Keep your hands clean. Remember to always wash your hands (and any siblings’ hands) as soon as you get home.

* Use a disinfectant wipe or spray several times every day to clean surfaces at home that are touched often.

* Teach older children to avoid touching their faces.

The Expert

Dr Sheffali Gulati, who has two decades of experience as faculty of the AIIMS Department of Paediatrics, specialises in child neurology and neurodevelopmental disorders. She has over 200 publications in international journals; has served as a member of the ICMR task force; and serves as an expert for development of the National Epilepsy Control Programme.

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