Coronavirus outbreak and kids

Advice on playdates, physical 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.

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.

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

Pfizer/BioNTech and Moderna are already conducting age de-escalation studies, in which the vaccines are tested in groups of children of descending age. Johnson & Johnson plans to do the same. Currently, the Pfizer/BioNTech COVID-19 vaccine is 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 March 2021, Pfizer/BioNTech announced promising results for a Phase 3 trial testing its vaccine in children ages 12 to 15. The trial enrolled 2,260 adolescents; half received the mRNA vaccine, the other received a saltwater placebo. The antibody 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 18 symptomatic cases of COVID-19 were reported during the trial, all in the placebo group. Vaccine-related symptoms were mild and comparable to older groups enrolled in earlier studies. The results were announced in a press release, not in a peer-reviewed, published study. Pfizer/BioNTech has submitted their data to the FDA with a request to expand emergency use authorization to children ages 12 to 15. The company has also started testing the vaccine in children younger than 12 years.

Moderna is conducting two vaccines studies — one in children ages 12 to 17, the other in children between the ages of 6 months and 12 years.

The age de-escalation studies 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 age de-escalation studies are smaller than the adult trials; rather than recruiting tens of thousands of participants, they will recruit 2,000 to 3,000 participants within each age group. As in the adult trials, some children in each trial will get a placebo.

The FDA will review 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. The CDC recently released guidelines for opening schools, noting that decisions about when and how to safely open schools should consider levels of community transmission.

The guidelines prioritize five key mitigation strategies, which, when layered together, should minimize the spread of COVID-19 in schools:

  • universal, correct use of masks that cover the mouth and nose
  • physical distancing
  • frequent hand washing
  • cleaning high-touch surfaces and maintaining healthy facilities
  • contact tracing, in combination with isolation and quarantine.

The CDC guidelines for physical distancing vary by school level and degree of community transmission, and they assume that everyone is masked. The CDC recommends at least 3 feet between students in elementary, middle, and high schools when community transmission is low or moderate. When transmission is high, students should be divided into separate groups (cohorts) that maintain 6 feet of distance from other cohorts throughout the day. The CDC also recommends a minimum of 6 feet between teachers and students at all times, and a minimum distance of 6 feet when masks are off, such as during lunch time.

The guidelines also recommend improving ventilation, by opening windows and doors, for example. Ideally, schools should have access to testing for students and teachers with symptoms, as well as routine screening to identify asymptomatic cases. And while they acknowledge that vaccination of teachers is important, they do not require it before returning to school.

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 mRNA COVID-19 vaccine?

The CDC, American College of Obstetrics and Gynecology (ACOG), and Society for Maternal-Fetal Medicine agree that the new mRNA COVID-19 vaccines (Pfizer/BioNTech and Moderna) should be offered to pregnant and breastfeeding individuals. However, the World Health Organization (WHO) recommends against use of either mRNA vaccine in pregnant women, unless the benefit to an individual outweighs the potential vaccine risks. Experts, including the WHO, believe it is most likely safe to get an mRNA COVID-19 vaccine if you're breastfeeding. As always, 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, research suggests that having COVID-19 might increase risk for premature birth, particularly for those with severe illness. Transmission of the virus from mother to baby during pregnancy is possible, but it appears to be a rare event.

Early mRNA vaccine trials did not deliberately include pregnant individuals. However, subsequent trials have enrolled women who are pregnant. One such study, conducted by the CDC, published reassuring preliminary results in NEJM. The trial looked at 3,958 women who received an mRNA COVID-19 vaccine between mid-December 2020 and late February 2021. All of the women were pregnant when they received the vaccine or became pregnant after getting the vaccine, and enrolled in the v-safe pregnancy registry, which tracks pregnancy and infant outcomes. Most of the women included in this analysis got the vaccine during their second or third trimester. Of these women, 827 had completed their pregnancy by the end of the study period. There were 712 live births, and the numbers of miscarriages and other adverse outcomes, including preterm birth and low birth weight, were similar to pregnancy outcomes reported in studies before the COVID-19 pandemic.

Another small study, which compared vaccine efficacy in pregnant and non-pregnant 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 are unlikely to reach or cross the placenta.

Is it okay to have babysitters or child care people in the house, given no known 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 play dates, 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, are a better option than indoor play dates. 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

Podcasts

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.

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