As the Omicron variant continues surging, hospitalization rates are ticking up, including among children. But questions remain about how much of a risk the new virus poses to kids, how parents can protect vulnerable young ones, and whether the rules are different this time around.
Fortune spoke with five pediatricians about the science, the risks, and how to care for your child should his or her test come back positive.
How many kids are getting sick?
It depends where you are. Dr. Jennifer Lighter, a pediatric infectious disease specialist at New York University Langone Hospital in New York City, said she’s currently treating more children with the flu than with COVID-19.
“There are 50 pediatric hospitalizations in New York State—not New York City, state,” Lighter told Fortune. “Because it’s so contagious, Omicron cases are sky-high right now, in both children and adults, but children progressing to severe disease is rare.”
Dr. Katharine Smart, president of the Canadian Medical Association and a pediatrician in the remote Yukon territory of Canada, said she has yet to see a single kid sick with the Omicron variant.
She noted, however, that Canada typically trails three to four weeks behind the U.S., so she expects numbers to rise soon, and because of the sheer contagiousness of Omicron, that means more kids will catch it. “What happens with kids corresponds with what’s happening in their community,” Smart said.
But at Comer Children’s Hospital in Chicago, pediatrician Dr. Chidimma Acholonu has seen more children in the hospital in the past month and a half than throughout the entire pandemic.
“Younger kids are testing positive and having symptoms,” Acholonu told Fortune. “Teenagers in particular are on par with adults in terms of needing respiratory support.”
“We’re definitely seeing a rise in pediatric infections in Boston,” Dr. Scott Hadland, chief of adolescent and young adult medicine at Massachusetts General Hospital, said. “But it’s worth highlighting that not all kids are admitted because they have COVID; when they come in for something else, they’re automatically given a test. There’s an enormous amount of COVID out in the community, and, inevitably, in the places kids live.”
How sick are kids getting?
We don’t have formal data yet, Hadland said, and current figures are anecdotal.
“There’s been a lot of attention paid to the idea that kids don’t get as sick as other age groups, but they can still get very sick and have enormous complications,” he said. “They’re at risk of long COVID and multisystem inflammatory syndrome, even with mild cases.”
But on the whole, children who are infected fare better than adults, doctors say. Immune response comes in two forms: innate immunity, which humans are born with; and adaptive immunity, which humans acquire after disease exposure. Kids are better able to combat the coronavirus because their innate immunity is stronger than that of adults, Lighter said.
The health impact of coronavirus in children is similar to that of the flu, she added; in fact, the flu is more fatal in that age group.
“Since the pandemic started, 548 children have died of COVID-19; that’s about the same as [die of flu in] a typical flu year,” she said. “No one really talks about that, because it’s taboo to equate COVID-19 to the flu. And you shouldn’t, because in adults, it’s not the same. But with kids, the health impact is similar; severe disease is rare, and the fatality rate is about two per 1 million.”
“In almost every case, you’d rather be a kid than an adult with COVID, and rather an adult than an elderly person,” Dr. Adam Ratner, director of the pediatric infectious diseases division at Hassenfeld Children’s Hospital at NYU Langone, told Fortune. “On a person-to person basis, kids are much less likely to have severe disease than adults. But when a huge chunk of the population is infected, you’ll see more severe disease in kids, even if it’s a rare outcome for any individual kid.
“While COVID certainly hits adults harder than children, in the aggregate, that doesn’t mean you don’t end up with very sick children,” Ratner said, adding that while the odds of severe disease for kids of all ages is low, it’s much higher for unvaccinated kids.
Are newborns protected?
Lighter’s recent study, published in September by the American Journal of Obstetrics & Gynecology, showed that among pregnant women who received the vaccine, the cord blood that went to their baby was rich in antibodies.
“Vaccinated and boosted moms will provide their babies protection for the first few months of life,” Lighter said. “Breastfeeding can also transmit antibodies, but not at the level of pregnancy vaccination.”
But for Omicron specifically, it’s impossible to know, Hadland said, “just because we know so little about the variant at this point.”
Should I take my kid to their pediatrician or to the ER?
As with any other ailment, parents should use their best judgment.
“Some kids who test positive don’t have to go either place,” Ratner said. “If they’re not having trouble breathing or don’t have a persistent high fever, they don’t necessarily need medical attention.” ERs are still concerningly busy, though, so a great way of making the call would be contacting a pediatrician first: “Most are happy to help make the decision and triage concerns.”
COVID is a respiratory illness, Smart said, which means parents should watch their COVID-positive kids the way they’d watch them with any other respiratory virus, such as the flu or bronchitis. If a child has trouble breathing, it’s time to go to the hospital.
“If a kid looks like they’re huffing and puffing, or they’re feeling short of breath and turning off-color, go to the hospital,” she said. Other main reasons for a hospital visit: if a child is really lethargic, not responding normally, or is dehydrated and unable to keep liquids down.
“In the ER, we’re only going to do so many things,” Acholonu said. “When a kid’s breathing becomes so labored that they compensate with other muscles and tire out, they may need to be intubated. We try to avoid that by giving them extra oxygen sooner through a nasal cannula.”
Signs of reduced breathing include panting visible in the throat or near the collarbone, or in the abdomen or rib cage. Kids may also show signs of dehydration when they cry but aren’t producing tears.
“Managing COVID is the same as managing other viruses—most of it is just TLC at home,” Acholonu said.
Can I give my kid a fever reducer?
At the beginning of the pandemic, some doctors expressed concerns about administering fever-reducing medicines to kids with COVID. Those concerns proved unfounded, Ratner said, and treating fevers with Motrin or Tylenol is fine.
“Whatever you would normally do for a kid with a fever—and for most people, that means something like ibuprofen—that’s fine to do with COVID,” he said.
Most COVID symptoms can be managed at home, Smart said, by administering Tylenol or Advil and providing ample clear fluids. “Most of the care children with a viral illness need is comfort care, not emergency care,” she said. “Hospitals are for medical treatments, like oxygen and IV fluids, which kids don’t usually need.”
Acholonu recommends fever reducers, too; children 6 months and older can alternate between Tylenol and Motrin every three hours; under 6 months, stick with Tylenol every six hours.
“It’s best to help your kids feel comfortable when they’re ill, and that includes reducing their fever,” Hadland said.
Should schools stay open?
The pediatricians Fortune spoke with agree: Yes, schools should stay open, by any means necessary.
Often, Lighter said, older adolescents can spread COVID-19 quite quickly, while younger kids aren’t as efficient. “They’re just breathing out so many fewer air particles,” she explained.
Closing schools during the initial surges was the right thing to do, Ratner said. But with all we know now about the virus and kids’ role, he added, keeping schools open is vital for society, for families, and for kids’ development.
“There are multiple things you can do to try to keep schools open as best you can,” he said. “The primary thing is anyone who’s eligible for vaccination, that’s everyone aged five and up, must get vaccinated.”
“I’m sending my kids to day care, because I know there are ways we can do this safely,” Hadland said. “There’s a lot we’ve known from the very beginning that still applies now. Stay home when you’re sick. Wear masks. Increase ventilation. Wash your hands.”
Acholonu agrees. “Most schools just aren’t equipped to operate virtually, and there’s a huge discrepancy in what kids are able to retain,” she said. “It’ll require flexibility, adjustments, and a lot of thinking outside the box, but we’ve got to keep them open.”
If my kid is sick, how can I protect other members of my family?
Adults transmit COVID-19 more efficiently than kids do, Lighter said. Most transmissions occur in the home, so the best way to protect children is to ensure every member of the family is fully vaccinated. “Even though severe disease is rare in children, we don’t want any.”
If a child is COVID-positive, any vulnerable member of the household, such as a grandparent or individual undergoing cancer treatment, should keep his or her distance.
“The parent will obviously take care of and be around that child,” Lighter said. “But then that child, according to the CDC, shouldn’t be around other people outside the house for five to 10 days.”
Especially important in households with kids is proper handwashing and wiped down surfaces, Acholonu said; kids are prone to ingesting pathogens through what they touch.
Should my toddler wear a mask?
Anyone who can wear a mask should do so, Acholonu said. “But if you have a toddler who’s just going to keep touching it and taking it off anyway, you’re doing more harm than good.”
While most airlines don’t mandate masks for children under 5, Ratner says data suggests kids age 2 and older do fairly well with mask wearing. “There’s kid-to-kid variability, and you have to choose your battles, but there are places where it can be very valuable.”
If a child isn’t able to wear a mask appropriately, it probably won’t offer the full benefit, Hadland added, but he encourages families to work together on proper mask usage. “Kids may not immediately do well with masks, but they learn.”
Can we have playdates?
Sure! But, if possible, bring them outdoors.
“As a parent, I don’t restrict my kids from doing things because of the flu, so I don’t do it because of COVID-19,” Lighter said.
Acholonu strongly encourages outdoor play: “We don’t want to make new problems while trying to solve other ones. Physical activity and socializing are key.”
Going into the new year, Smart recommends keeping your playdate bubble as small as possible. “Maybe now isn’t the time for a 50-person party. Maybe limit it to two or three other families, also fully vaccinated.”
Hadland says the same: “If your child wants to have a playdate with another kid from their class, your child and that child have already been mixing in another setting and probably doesn’t substantially increase the risk to hang out with them outside of school.”
Many parents look for 100% guarantees of never getting COVID, Smart said. “But, unfortunately, that’s now how infectious diseases work. It’s about risk mitigation, and the bottom line is, most kids do fine.”
Smart likens basic COVID protections to basic driving safety. “Our kids ride in cars even though we know the leading cause of death in kids is motor collisions,” she said. “So we use car seats and seat belts. We buy the best safest vehicle we can afford; we obey the speed limit. COVID’s like that; these layers of protection make us as safe as possible, even though it’ll never be zero.”
Should I buy a pulse oximeter for my kid?
Many adults have been advised to keep a pulse oximeter on hand as a tool for measuring oxygen saturation in the blood. This is because adults can be prone to silent hypoxia, which is when blood oxygen levels plummet with no discernible feeling—until it’s too late. But a pulse oximeter isn’t nearly as useful for kids.
“Kids with low oxygen use accessory muscles to breathe,” Smart explained. “If their oxygen levels are dropping, they suck in at the neck above the clavicle, between the ribs, and breathe quickly. You don’t need to buy a pulse ox for a kid; if they have low blood oxygen, you’ll notice.”
Smart has a basic rule about pediatric care which remains true even during COVID: You can tell when something’s wrong with a kid by looking at them. Kids look fine when they’re fine, and don’t look fine when they’re not.
“You won’t have a kid playing around, acting normally, if their blood oxygen is at 80%,” she said. “Likewise, you won’t have a kid who looks really unwell but is okay. If they’re lying in bed, and you can’t get them to play, and they’re refusing fluids and not responding to their environment, those are danger signs.”
Hadland also encourages parents to forgo the pulse oximeter: “It’s not needed in most cases, and just puts them in the position of worrying about yet another thing.”
What is the best thing I can do to keep my kid safe?
Every pediatrician agrees: Get vaccinated.
Boosters are now available for teens age 16 and older, Hadland said, which is key, as boosters appear to make a huge difference in Omicron protection. Everyone in the household who’s eligible needs to get vaccinated, because, as Lighter points out, most transmissions happen at home.
Getting fully vaccinated and boosted, limiting contact with unvaccinated people, and wearing high-quality, well-fitting masks in public are top priorities, Smart said.
“As a parent, those are the things you can control,” she said. “What’s most important are the layers of protection. One thing isn’t a magic bullet; it’s about doing all these things together, and making smart choices.
“We know the vaccines aren’t perfect in prevention, but they work very well in preventing severe disease and hospitalization; that’s so important to understand,” Smart said. “Bad outcomes can be avoided, and that’s what matters.”
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