Earlier this summer, the American Academy of Pediatrics made recommendations that contrasted with those from the CDC, emphasizing the need to do everything possible to prevent COVID infection in children. Specifically, they recommended that even vaccinated adults who were around unvaccinated children in schools continue to mask indoors. This more conservative stance initially caused confusion, but the CDC has since aligned their guidelines more closely with pediatricians. Nevertheless, there remain policymakers, politicians, and even adult physicians who promote a narrative of minimizing COVID infection in children.
Why do pediatricians see COVID differently? The answer lies in risk tolerance. Pediatricians have a low appetite for risk. Medical advances, combined with fewer co-morbidities, have made childhood death a rarity. We are fortunate that our patients by and large survive their illnesses and have long lives ahead of them. As a result, the pediatric approach to risk analysis focuses heavily on morbidity as well as mortality; poor outcomes (short of actual death) could impact our patients’ lives and futures in a profoundly different way than for adults. This more careful approach has been a hallmark of pediatrics for many decades, and has served the children of this nation well.
Any discussion of pandemic risks and interventions for children must also occur within this framework. Claims that children “do not get that sick” from COVID confuse morbidity and mortality. Hospitalization rates from this week alone illustrate that children can, and do, get very sick. Although Delta is not more severe than its predecessors, as community rates continue to climb, more children will get sick. Thankfully, most will have mild illnesses. Almost all will survive. And although we now know about some risk factors, there remains an inexplicable randomness to COVID severity: Clinicians cannot always predict who will end up severely ill, who will get long COVID, and who will get away with minimal symptoms.
Long-term consequences remain unknown for children who do develop serious illness (and perhaps even those who do not). Biomarkers associated with inflammation and clotting have been identified in children with even mild disease, and because of concerns about cardiac dysfunction after COVID infection, pediatricians have had to change how we approach sports clearance. We are also learning that COVID can have potentially concerning impacts on brain function regardless of infection severity; preliminary evidence indicates that it can decrease IQ, cause impairments in sustained attention, and even cause memory deficits similar to those in Alzheimer’s. Yet other consequences may reveal themselves with further time and further study.
None of this is written to generate fear. The extent of these findings remains unknown, and the degree to which they will persist is as yet unknowable. Reassuringly, some data suggest that the effects of long COVID, for example, improve substantially about three months after infection.
But it is still true that COVID infection has the potential to affect the lives of our patients over a far longer time frame than might be true for adults. To complicate matters, isolation and virtual learning have had profound impacts on our patients. Rates of mental illness, poor sleep, and suicide attempts in children skyrocketed last year. The relative risks of these two sets of consequences must be weighed carefully. On balance, most pediatricians believe strongly that in-person school is a priority, but also that we must do everything we can to make school as safe and COVID-proof as possible.
How? Vaccination. Ventilation. Testing. Quarantining. Masking. These five strategies appear to have the most impact on transmission. Of the five, vaccination is most effective. Until younger children are eligible for vaccination, we must surround them with a cocoon of vaccinated adults and optimize all the other measures. Improve ventilation. Wash hands, implement easy access to testing, and stay home when sick. Wear masks. Even if the relative impact of each of these interventions is variable, the COVID-prevention benefits from these measures outweigh the harms. But it should also be our goal to get to a point where we no longer need these additional measures.
Every school in this country should be using this layered approach to keep students safe. Instead, school districts in several states are doing away with contact tracing, mask requirements, and even quarantines for exposed children. Some policymakers continue to believe that preventing COVID in children is unnecessary, and decisions are being made without input from the very pediatricians who see and manage COVID in children. Unfortunately, resistance to these interventions is a recipe for the persistent spread in schools, resulting in more cases, more quarantines, and ultimately more emotional and educational consequences for the children of this nation.
It is true: Our children deserve this to be a normal school year. But it is our adult choices that will decide when and if that is achievable.
Krupa Bhojani Playforth is a pediatrician and can be reached at The Pediatrician Mom.
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