COVID-19 and Children: Exclusive Interview with Pediatrician (Updated)

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COVID-19 raises questions for everyone and perhaps even more so for parents: how risky is it for children? Which precautions are the most important? What to do if they have a fever or other symptoms?

So much information is being shared on the internet and by other parents. Juggling with it can bring extra worries, if not headaches.

To learn more, we interviewed Dr. Eddie Cheung 張蔚賢醫生, a pediatrician in Hong Kong who has two children himself and provides daily guidance to parents in this challenging period.

Are children less or more at risk of being infected with COVID-19 than adults?

From limited information published so far, children appear to be less susceptible to COVID-19 infection. A study published on February 20 in the leading medical journal The Lancet indicates very low infection rates in children under 5 years old. Also, most infected children have mild clinical manifestations, and most of them do not have fever or symptoms of pneumonia. To date, the largest review (Pediatrics 2020; 145(6):e20200702) of more than 2,000 children with COVID-19 in China showed that less than 6% of those infected children had severe disease. The prognosis is generally good for infected children and they usually recover within 1-2 weeks after disease onset. Few may progress to respiratory or multi-organ failure. Deaths in children are rarely reported.

How many children have been infected with COVID-19 so far?

Data is changing every day. Based on the Report of the WHO-China Joint Mission on Coronavirus Disease 2019 regularly updated, data suggests that the attack rate for individuals 18 years or below is relatively low, at about 1.7%. But since many of the children infected with COVID-19 have only mild or even no symptoms, the extent of the infection among children is difficult to determine.

For children specifically, what are the main differences between SARS and COVID-19?

From limited information published from past SARS (Severe Acute Respiratory Syndrome coronavirus, SARS-CoV) and MERS (Middle East respiratory syndrome coronavirus, MERS-CoV) outbreaks, infection among children was relatively uncommon. This observation seems to be similar for children with the current COVID-19 outbreak so far.

If a child is infected with COVID-19, what are the risks?

There have been very few reports of the clinical outcomes for children with COVID-19 to date. Limited reports from China suggest that children with confirmed COVID-19 may present with mild symptoms and though severe complications (e.g., acute respiratory distress syndrome, septic shock) have been reported, they appear to be uncommon. Early observations in a recent article in JAMA (Journal of the American Medical Association) shows that even among the youngest and presumably most vulnerable infants, none required intensive care, mechanical ventilation, or had severe complications (including death). However, as with other respiratory illnesses, certain populations of children may be at increased risk of severe infection, such as children with underlying health conditions.

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What are the most important precautions parents should know?

Person-to-person spread of the virus that causes COVID-19 has been seen among close contacts. Children should engage in usual preventive actions to avoid infection, including cleaning hands often using soap and water or alcohol-based hand sanitizer, and avoiding people who are sick. It is also very important to avoid unnecessary social contact, e.g. playdates.

A strong immune system is important. How to ensure my children keep a strong one?

To be honest, we are not sure how we can effectively prevent COVID-19 infection in terms of body defense mechanisms. But one thing we know so far is that, for adults who died or have serious medical conditions associated with COVID-19 infection, many of them also suffer from co-existing bacterial infection. Theoretically, if our immune system is stronger, the chance of co-existing bacterial infection will be less. Having a balanced diet, adequate rest, good hydration and regular exercise may contribute to a better immune system. Moreover, if we have a strong immune system and better baseline health, the chance of complete and speedy recovery should be higher.

Children are often sick. What to do if my child has a fever or symptoms similar to those of COVID-19?

This is the tricky part. Many symptoms associated with COVID-19 infection, especially in children, are very much like those of common cold and mild in severity. To medical professionals, diagnosing a case of COVID-19 infection simply by judging from the symptom profile is extremely difficult. In order to make a better judgement, we also need to get information from parents and family to see if there was any suspicious travel history, any contact with high-risk individuals or any clustering of sick people in certain families or communities. In case of doubts, we may need to arrange lung imaging e.g. a chest X-ray or even referring to public hospital for airway secretion analysis to confirm or exclude COVID-19 infection.

To parents, if a child has cold-like symptoms for more than 3-4 days, with or without fever, it is better to consult a doctor.

This is a stressful time for parents. As a father, what can you tell parents to help them better manage this period?

We are all undoubtedly and significantly affected by this epidemic both socially and psychologically. But we should not panic or be over-pessimistic. As far as children are concerned, data so far does not suggest that children infected with COVID-19 are more susceptible to develop serious consequences or complications. We just need to be careful and should tighten up every family member’s concept of personal hygiene. Reducing unnecessary social contact and social gatherings effectively reduces the chance of contracting the infection. With the help of online learning materials, children should be easily occupied in a positive way. By the way, more family time is always good for family bonding!

Children often touch their face and it’s hard for them to keep a mask on. Should children really wear one?

From my observation, lots of kids may touch their faces, eyes and noses more if they have a mask on. This may defeat the purpose of avoiding droplets with infected materials to have contact with our mucous membrane, including our eyes, nose and mouth. For kids below 1 year old, it is almost impossible to keep a mask on them properly. Parents are always adjusting the position of mask on their child’s face, ignoring the fact that they may not have cleaned their hands before doing so. Hand hygiene and avoidance of social contact are still the keys to prevention of COVID-19 infection. Kids should be taught not to touch surrounding objects unnecessarily. They should be reminded to frequently clean their hands with soap and water, or alcohol hand-rub, when they are in public areas.

Is it safe to travel with my children?

Personally I do not think it is a good idea to travel during this period. Spending hours in a confined area like a flight cabin and having very close contact with others make proper infection control measures almost impossible.

How worried are your patients?

Almost all parents are worried. This is because of the rapid progression of the outbreak, inadequate knowledge of this novel infection and its impact on social and school life.

Any final advice for parents?

Stay alert but stay calm. We shall overcome!

Dr. Eddie Cheung 張蔚賢醫生 is a specialist in paediatrics. He received his paediatric training in Queen Mary Hospital and post-fellow paediatric cardiology training in Grantham Hospital/ Queen Mary Hospital. He is a Fellow of the Hong Kong College of Cardiology, the Vice President of Hong Kong Society of Paediatric Cardiology and Consultant of Hong Kong Association of Cleft Lip and Palate. He is currently working as Director of Paediatric Centre of HK Medical Consultants and serves as Infection Control Officer at the Hong Kong Adventist Hospital.