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Coronavirus outbreak and kids

October 7, 2021

Advice on playdates, social distancing, and healthy behaviors to help prevent infection

Children's lives have been turned upside down by this pandemic. Between remote schooling and playdates being cancelled, children's routines are anything but routine. Kids also have questions about coronavirus, and benefit from age-appropriate answers that don't fuel the flame of anxiety. It also helps to discuss — and role model — things they can control, like hand washing, physical distancing, and other health-promoting behaviors.

Visit our Coronavirus Resource Center for more information on coronavirus and COVID-19.

Which COVID-19 vaccines has the FDA authorized for children?

On May 10, 2021, the FDA expanded its emergency use authorization (EUA) for the Pfizer/BioNTech COVID-19 vaccine to include adolescents 12 to 15 years old. Previously, the Pfizer vaccine was authorized for use in children 16 years and older. For now, this is the only vaccine authorized in the U.S. for anyone under age 18.

Pfizer has been conducting age de-escalation studies, in which its vaccine is tested in groups of children of descending age. The EUA’s expanded authorization was based on results from a Phase 3 trial of children ages 12 to 15. The trial enrolled 2,260 adolescents; half received the Pfizer mRNA vaccine, the other received a saltwater placebo.

The immune response in the vaccinated adolescent group was even stronger than that in vaccinated 16- to 25-year-olds enrolled in an earlier study. In addition, a total of 16 symptomatic cases of COVID-19 were reported during the trial, all in the placebo group, which meant that the vaccine had been 100% effective in preventing COVID-19.

Vaccine-related side effects were mild and included pain at the injection site, tiredness, headache, chills, muscle pain, fever, and joint pain. Pfizer has also started testing the vaccine in children younger than 12 years.

I have been hearing about heart problems in kids and young adults following the COVID vaccine. Should I still get my child vaccinated?

There has a been a higher-than-expected number of heart inflammation cases after vaccination with the mRNA COVID-19 vaccines, particularly among boys and young men. However, the CDC still strongly recommends that all children 12 years and older be vaccinated.

As of July 12, 2021, 1,047 reports of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the outer lining of the heart) had been reported in people under age 30, particularly in male teens and young adults, after vaccination with the Pfizer/BioNTech or Moderna mRNA vaccines The CDC’s Advisory Committee on Immunization Practices (ACIP) has said available data "suggest likely association of myocarditis with mRNA vaccination in adolescents and young adults." Even with the increased risk, heart inflammation is a rare occurrence.

Myocarditis and pericarditis after vaccination was most common in males ages 16 to 24. Cases tended to occur within several days after the second mRNA vaccine dose. Most people who developed myocarditis or pericarditis had mild cases and recovered completely after treatment.

If your child develops any of the following symptoms within a week of vaccination, seek medical care:

  • chest pain
  • shortness of breath
  • feeling like your heart is beating fast, fluttering, or pounding.

This or any other potential significant side effect of a vaccine is always of special concern in children. While the risk of COVID causing severe illness and hospitalization is much lower compared to adults, it’s important to remember that at least 491 children ages 0 to 17 years have died from COVID. In addition, long-term adverse health effects even after mild infection in children are now being recognized.

It’s understandable that many parents will be uncomfortable with either choice, vaccinate now or wait. But the rise of the more contagious and possibly more dangerous Delta variant, combined with the protection offered by herd immunity, supports the CDC recommendation that all children ages 12 year and older get vaccinated.

How does COVID-19 affect children?

Children, including very young children, can develop COVID-19. Many of them have no symptoms. Those that do get sick tend to experience milder symptoms such as low-grade fever, fatigue, and cough. Some children have had severe complications, but this has been less common. Children with underlying health conditions may be at increased risk for severe illness.

A potentially severe and dangerous complication can occur in children. Called multisystem inflammatory syndrome in children (MIS-C), it can lead to life-threatening problems with the heart and other organs in the body. In this condition, different body parts, such as the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs, can become inflamed.  

Symptoms of MIS-C can include

  • fever lasting more than a couple of days
  • rash
  • "bloodshot eyes"(redness of the white part of the eye)
  • stomachache
  • vomiting and/or diarrhea
  • a large, swollen lymph node in the neck
  • neck pain
  • red, cracked lips
  • a tongue that is redder than usual and looks like a strawberry
  • swollen hands and/or feet
  • irritability and/or unusual sleepiness or weakness.

Many conditions can cause symptoms similar to those of MIS-C. Your doctor will first want to know if your child has been around someone who has tested positive for the virus and will ask about all of the above symptoms. Results of the physical examination, a COVID-19 diagnostic or blood antibody test, and other medical tests that check for inflammation and how organs are functioning can support the diagnosis of MIS-C.

Call the doctor if your child develops symptoms, particularly if their fever lasts for more than a couple of days. If the symptoms get any worse or just don't improve, call again or bring your child to an emergency room.

Doctors have had success using various treatments for inflammation, as well as treatments to support organ systems that are having trouble. While there have been some deaths, most children who have developed MIS-C have recovered.

The journal Lancet Child & Adolescent Health published a study that looked at the long-term health effects of MIS-C on 46 children hospitalized with MIS-C between April and September 2020. All of the children had systemic inflammation; most also had problems related to gastrointestinal, heart, and kidney function, and clot formation. By six months after the children were discharged from the hospital, most of these problems had resolved, without lasting organ damage in most cases. About one-third of the children continued to have muscle weakness, fatigue, and mental health difficulties. But the study could not determine whether these effects were due to MIS-C in particular, or to hospitalization, or other factors.

When will children be able to get the COVID-19 vaccine?

In September 2021, Pfizer/BioNTech announced that its COVID-19 vaccine is safe and effective in children ages 5 to 11 years. Pfizer has submitted its data to the FDA and has applied for emergency use authorization (EUA) for this age group. An advisory committee to the FDA will meet to discuss the matter on October 26th.

In the Pfizer study, 2,268 children, ages 5 to 11, received two doses of the COVID-19 vaccine, spaced three weeks apart, while a smaller group of children received a placebo. The children in this study were given 10 microgram doses of the vaccine, which is lower than the 30 microgram doses being given to Pfizer vaccine recipients ages 12 years and older. (Earlier results had found increased side effects for the younger children at the higher dose.) Antibody responses and side effects in the 5-to-11-year-olds were compared to those of 16-to 25-year-old participants from a previous study.

The trial results showed that the antibody response in 5-to-11-year-olds was similar to the antibody response in teens and young adults. Side effects were also comparable. There were not enough COVID cases in the study population to tell whether the vaccine protected against infection or illness.

In May 2021, the FDA expanded its EUA for the Pfizer/BioNTech COVID-19 vaccine to include adolescents 12 to 15 years old. Previously, the Pfizer vaccine was authorized for use in children 16 years and older, while the Moderna and Johnson & Johnson vaccines are authorized for people 18 years and older.

In June 2021, Moderna applied to the FDA for EUA of their mRNA vaccine for use in children ages 12 to under 18 years. The company announced promising results of a Phase 2/3 study in adolescents in May. The study enrolled 3,732 children ages 12 to 17. Two-thirds received two doses of the Moderna mRNA vaccine and one-third received a placebo. The immune response generated by the vaccine in adolescents was found to be at least as good as the immune response the vaccine generated in adults. Starting two weeks after the second vaccine dose, no cases of COVID-19 occurred in the vaccine group, compared to four cases in the placebo group. Vaccine side effects were mild to moderate, with injection site pain, headache, fatigue, muscle pain, and chills being the most common. The study did not identify any significant safety concerns. The results were announced in a press release. Moderna is also studying the vaccine in children between the ages of 6 months and 12 years.

Age de-escalation studies, in which the vaccines are tested in groups of children of descending age, are done to confirm that the vaccines are safe and effective for each age group. They also identify the optimal dose, which must be effective, but with tolerable side effects.

The FDA reviews data from the de-escalation trials to decide whether to authorize the vaccines for each age group.

What needs to happen for schools to open safely?

School closures have impacted children on many fronts, from academics and social interaction to equity, food security, and mental health. Safely returning children to in-person instruction in fall 2021 is a priority for the CDC.

In July 2021, the CDC recommended that all teachers, staff, students, and visitors to schools wear masks while indoors, regardless of whether or not they are vaccinated. They also recommend that everyone who is eligible for vaccination get the vaccine.

There are several other prevention strategies that, when layered together, should minimize the spread of COVID-19 in schools. These include physical distancing; screening, testing, and contact tracing; staying home when sick; and frequent handwashing. Schools should also do their best to improve ventilation, by opening windows and doors, for example. Decisions about some of these prevention strategies may depend on levels of community transmission.

Are kids any more or less likely than adults to spread coronavirus?

Most children who become infected with the COVID-19 virus have no symptoms, or they have milder symptoms such as low-grade fever, fatigue, and cough. Early studies suggested that children do not contribute much to the spread of coronavirus. But more recent studies raise concerns that children could be capable of spreading the infection.

Though the recent studies varied in their methods, their findings were similar: infected children had as much, or more, coronavirus in their upper respiratory tracts as infected adults.

The amount of virus found in children — their viral load — was not correlated with the severity of their symptoms. In other words, more virus did not mean more severe symptoms.

Finding high amounts of viral genetic material — these studies measured viral RNA, not live virus — in kids does not prove that children are infectious. However, the presence of high viral loads in infected children does increase the concern that children, even those without symptoms, could readily spread the infection to others.

Should parents take babies for initial vaccines right now? What about toddlers and up who are due for the standard vaccines?

Getting early immunizations in for babies and toddlers — especially babies 6 months and younger — has important benefits. It helps to protect them from infections such as pneumococcus and pertussis that can be deadly, at a time when their immune system is vulnerable.

Now that doctors’ offices and clinics have taken specific measures to prevent COVID-19 spread, vaccinations for children don’t need to be delayed. That’s especially true for children with special conditions.

However, if you are concerned about going to an office or clinic, it’s best to call and let them know how you feel. Find out what precautions they are taking to keep children safe, and discuss your particular situation, including not only your child's health situation, but also the prevalence of the virus in your community and whether you have been or might have been exposed. Together, you can make the best decision for your child.

When do you need to bring your child to the doctor during this pandemic?

If you have any concerns about your child, call your doctor's office for advice. Many practices are offering phone or telemedicine visits, and it's remarkable how many things can be addressed that way.

Some things, though, may require an in-person appointment, including:

  • Illness or injury that could be serious, such as a child with trouble breathing, significant pain, unusual sleepiness, a high fever that won't come down, or a cut that may need stitches or a bone that may be broken. Call your doctor for guidance as to whether you should bring your child to the office or a local emergency room.
  • Children who are receiving ongoing treatments for a serious medical condition such as cancer, kidney disease, or a rheumatologic disease. These might include chemotherapy, infusions of other medications, dialysis, or transfusions. Your doctor will advise you about any changes in treatments or how they are to be given during the pandemic. Do not skip any appointments unless your doctor tells you to do so.
  • Checkups for very young children who need vaccines and to have their growth checked. Check with your doctor regarding their current policies and practices.
  • Checkups and visits for children with certain health conditions. This might include children with breathing problems whose lungs need to be listened to, children who need vaccinations to protect their immune system, children whose blood pressure is too high, children who aren't gaining weight, children who need stitches out or a cast off, or children with abnormal blood tests that need rechecking. If your child is being followed for a medical problem, call your doctor for advice. Together you can figure out when and how your child should be seen.

Bottom line: Talk to your doctor. The decision will depend on a combination of factors including your child's condition, how prevalent the virus is in your community, whether you have had any exposures or possible exposures, what safeguards your doctor has put into place, and how you would get to the doctor.

I am pregnant and plan to eventually breastfeed my baby. Is it safe for me to get a COVID-19 vaccine?

In September 2021, the CDC "strongly recommended" that women who are pregnant, thinking about becoming pregnant, or were recently pregnant, including those who are breastfeeding, should get vaccinated against COVID-19. The American College of Obstetrics and Gynecology (ACOG) and the Society for Maternal-Fetal Medicine also agree that all pregnant and breastfeeding individuals should be vaccinated.

The World Health Organization (WHO) recommends use of a COVID-19 vaccine in pregnant women when the benefit to an individual outweighs the potential vaccine risks. Experts, including the WHO, believe it is most likely safe to get a COVID-19 vaccine if you're breastfeeding. Similar to any decision regarding over-the-counter medications and supplements during pregnancy, your own doctor is in the best position to advise you based on your personal health risks and preferences.

Here are some factors to consider. First, although the actual risk of severe COVID-19 illness and death among pregnant individuals is very low, it is higher when compared to nonpregnant individuals from the same age group. In addition, COVID-19 increases risk for premature birth, and possibly also for other undesirable pregnancy outcomes. Transmission of the virus from mother to baby during pregnancy is possible, but it appears to be a rare event.

The CDC’s stronger recommendation followed safety data released in August 2021. The study enrolled nearly 2,500 women who received a COVID-19 vaccine, either before becoming pregnant or during their first 20 weeks of pregnancy, and found that they did not have an increased risk of miscarriage.

A previous study, conducted by the CDC and published in NEJM, found the COVID-19 vaccines to be safe when given during the second or third trimester.

Another small study, which compared vaccine efficacy in pregnant and nonpregnant women, was published in the American Journal of Obstetrics and Gynecology. The study found that mRNA vaccines effectively produce antibodies that protect against SARS-CoV-2 in women who are pregnant or breastfeeding, and that this immunity is passed from mother to newborn through the placenta and breast milk.

mRNA vaccines do not contain any virus, so they cannot cause COVID-19 in a woman or her baby. And our bodies quickly break down and eliminate mRNA particles used in the vaccine, so they cannot reach or cross the placenta.

Is it okay to have babysitters or child care people in the house given no know exposures or illness in their homes?

The truth is that the fewer people you and your children are exposed to, the better. However, the reality is that not every family will be able to have a parent at home at all times.

All people can do is try to minimize the risk by doing things like:

  • choosing a babysitter who has minimal exposures to other people besides your family
  • limiting the number of babysitters. If you can keep it to one, that's ideal, but if not keep the number as low as possible
  • making sure that the babysitter understands that he or she needs to practice physical distancing, and needs to let you know (and not come to your house!) if he or she feels at all sick or has a known exposure to COVID-19
  • having the babysitter limit physical interactions and closeness with your children, to the extent that this is possible
  • making sure that everyone washes their hands frequently throughout the day, especially before eating.

Can you provide some guidance regarding play dates? My kids really miss their friends.

 With infection rates still high in much of the country, it’s best to minimize playdates, or to limit them to a couple of children or families with whom you have been socializing during the pandemic.

Outdoor play dates, where you can create more physical distance, is a better option than indoor playdates. Something like going for a bike ride, or a hike, allows you to be together while sharing fewer germs (bringing and using hand sanitizer is still a good idea). You need to have ground rules, though, about distance and touching, and if you don't think it's realistic that your children will follow those rules, then don't do the play date even if it is outdoors.

You can still go for family hikes or bike rides where you're around to enforce social distancing rules. Family soccer games, cornhole, or badminton in the backyard are also fun ways to get outside.

You can also do virtual play dates, using a platform like FaceTime or Skype so children can interact and play without being in the same room.

More about kids and coronavirus


Back to school: It's never been more complicated (recorded 7/30/2020)

Sending kids back to school in the fall is always a hopeful time in America. For most families, school is a vital part of the community. With the surge in coronavirus in many areas of the country, getting kids back in the classroom safely will require a major re-evaluation to reduce transmission rates that can impact people of all ages. We talked to Allan Geller, a senior lecturer in the Department of Social and Behavioral Sciences at Harvard's T.H. Chan School of Public Health. Like it or not, for school teachers and administrators, things are going to be different. Don't expect the traditional.


Visit our Coronavirus Resource Center for more information on coronavirus and COVID-19.

Image: 4X-image/Getty Images



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