In June 2021, we implored the public to recognize the flawed perspective of pediatric COVID-19 risk that pervaded all discussions of the disease. This fallacious viewpoint held that pediatric risk was minimal to nonexistent, and thus measures to protect them — both pharmaceutical and non-pharmaceutical — were unjustified. Though lower risk than adults, children have still suffered greatly from the pandemic.
As of today, over 1,000 U.S. children are documented to have died from COVID-19 and 55 from MIS-C since the beginning of the pandemic — a number far in excess of multiple diseases we prevent with vaccines even after stratifying to an annual average. We must reiterate: children are not supposed to die. Deaths in childhood represent an extremely premature loss of life and are for that reason uniquely devastating. We are also fortunate to live in a country where they are highly anomalous, further underscoring their tragedy. The ripple effects of those losses will reverberate for generations and will have profound implications for health equity, as the burden of these deaths is extremely disproportionate. Today, as we contend with the Omicron variant, we’re continuing to pay for our country’s failures to respond appropriately to the crisis of COVID-19 in kids and it’s painfully clear that the health of our children remains at the bottom of the priority list.
The Risks of Pediatric COVID-19
While severe COVID-19 in children is rarer than in adults, the risk exists. With soaring infections and recent record high hospitalization rates, countless children stand to be harmed. Severe COVID-19 in children may require high acuity care including PICU admission, mechanical ventilation, and pressor support — and unfortunately, death may occur anyway. CDC’s tracker has identified over 80,000 COVID-19 hospitalizations in those ages 0 to 17 since August 2020. The current rate of pediatric COVID-19 hospitalization is higher than it has ever been.
Many, though not all, hospitalized children have comorbidities, which are associated with an increased risk of severe COVID-19. These children are as worthy of life and normalcy as those without comorbidities — suggestions that their deaths are normal or acceptable are ableist and unhippocratic. Children’s hospitals are clearly strained by the sheer volume of patients. Suffice to say, the current numbers of COVID-19 hospitalizations in children are very concerning.
One of the most challenging aspects of COVID-19 is that acute illness is not always the biggest threat. MIS-C (multisystem inflammatory syndrome in children) can occur with infection of any severity, including apparently asymptomatic infection, following a lag of 2 to 5 weeks. This is particularly significant given the current massive surge in pediatric COVID-19 infections. MIS-C often (73% of the time) requires ICU-level care, as it can cause hyperinflammation, vasculitis, coronary artery aneurysms, shock, and appendicitis, among other disease manifestations. Importantly, though the risk of developing MIS-C is low, it is not evenly distributed across children of all backgrounds. Those of lower socioeconomic status or minoritized ethnic and racial background have disproportionately elevated risk, likely reflecting a much greater risk of infection in the first place. Fortunately, in the majority of cases, pediatric patients survive MIS-C and appear to make complete recoveries. However this isn’t always the case. It is also important to note that MIS-C in a neonate has now been reported. Given the substantial risk of infection in pregnancy to both the mother and child, efforts to ensure high levels of vaccination among pregnant individuals are imperative.
PASC (post-acute sequelae of SARS-CoV-2 infection) and MIS-C have imprecise and variable case definitions, which hampers attempts to quantify them. PASC has over 200 possible associated symptoms, and many pathologies can result as sequelae of COVID-19. Though the condition does appear to be less prevalent in children than adults, determining the incidence of PASC in children is particularly difficult because children, especially younger children, may not be able to readily express that they are suffering from PASC symptoms, resulting in under-ascertainment. Though challenging to precisely quantify the scale of the problem in children and research is limited, many clinics for pediatric PASC have opened, suggesting the problem is significant and more pervasive than initially apparent.
Additionally, unlike MIS-C, in which a number of effective therapies and leads have been identified, there is no such equivalent for PASC. There are also concerns surrounding the use of unproven therapies for the management of PASC. This could be especially harmful for children, who lack the agency to refuse treatments. PASC in childhood could disrupt the ability to study and learn, which can have substantial consequences later in life. Indeed, a recent analysis in the Morbidity and Mortality Weekly Report suggests that pediatric COVID-19 may be associated with an elevated risk of developing diabetes, which has lifelong consequences.
What About COVID-19 Vaccines in Kids?
Despite extensive accumulated data supporting the value and necessity of pediatric vaccination, the number of vaccinated children is far too low. Since our last commentary on COVID-19 and kids, the vaccination landscape has evolved, with individuals as young as 5 years being eligible, and those as young as 12 being eligible for boosters (and recommended to receive them).
These vaccines have repeatedly demonstrated excellent effectiveness against COVID-19, especially for severe disease, and excellent safety — certainly far safer than COVID-19. The burden of disease disproportionately affects the unvaccinated, something readily apparent in pediatric COVID-19 hospitalizations. Yet, there continues to be significant COVID-19 vaccine hesitancy among caregivers, in large part due to rampant vaccine misinformation. Only approximately half of 12- to 17-year-old children are fully vaccinated, with the unvaccinated at significantly heightened risk for COVID-19 and its sequelae. The picture is even more grim for children ages 5 to 11: each week, just 1% of this age group is receiving their vaccine, and overall, just 25% have had at least one dose. Vaccination has been shown to reduce the risk of hospitalization due to COVID-19 in children ages 12 to 17 by a factor of 10. COVID-19 vaccination has even been shown to reduce the likelihood of MIS-C among 12- to 18-year-olds by 91%, and even among breakthrough MIS-C cases, the need for life support measures was lower.
The risks of COVID-19 are manifold and serious, and, thus far, there is no age demographic for whom the risks of COVID-19 vaccination exceed the benefits. It is furthermore unacceptable that vulnerable children under the age of 5 do not have options for COVID-19 vaccination, especially as this current wave is affecting them so intensely. COVID-19 vaccines for the under 5 age group are urgently needed. U.S. regulatory bodies must ensure they arrive in the most expedient manner possible, and explain any changes causing further delay.
It’s Time to Prioritize Kids
Parents and caregivers and their children have been left behind. Those who work in pediatrics are familiar with children’s health issues regularly taking a backseat to other “more pressing” health issues. However, we had hoped that upon recognition of the seriousness of pediatric COVID-19, how connected we all are, and simple conscience to do what is best, that we might be further along in protecting kids. Instead, time and time again throughout this pandemic, adults have let children down. Exhausted and confused caregivers are inundated with conflicting opinions from seemingly credible sources about how to proceed. Masks are safe and essential non-pharmaceutical interventions (NPIs), but parents hear demands to “unmask the children” because they will cause “irreparable” harm to their children’s social and neurocognitive development. Test-to-stay programs in schools are underutilized and rapid testing in the U.S. is suboptimal. Many schools lack the infrastructure and financial means to institute safer ventilation.
We should have had more expeditious vaccine trials for children, more effectively promoted vaccinations, and better addressed misinformation before and after authorization. Our leaders should have had better support for NPIs rather than relying solely on vaccines. Schools are essential and should remain open, but only if the proper NPIs are in place, which we had more than enough time to prepare for over these past 2 years — but did not. Parents are told to throw caution to the wind and send their vulnerable children to schools that do not or cannot follow essential precautions.
Our leadership has failed to prepare for this winter COVID-19 surge despite having suffered two previous surges. All the things we ask for are feasible, yet they’re not being done. The health of our children continues to be this country’s last priority. Our children deserve better — how much longer will we fail to deliver?
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.