Pediatrics and COVID-19
There is much discussion about the safety regulations and policies that surround COVID-19. People are often commenting because the guidelines change so frequently. This is true. The guidelines are changing, sometimes even hourly as new information is gathered.
Coronavirus or COVID-19 is a novel virus. This means it is one that has never been seen before. It is a virus, so we do know somethings about how viruses behave in general, but the key is that it is novel. This means, it is not a virus that has been seen before so how it exactly works is unknown.
Viruses behave in a certain way. Viruses are extremely tiny. They enter the cells of your body. Once inside a cell, the virus will replace the natural cell duplication process with the virus’s duplication process. The cell no long reproduces itself but instead reproduces the virus. It can then travel throughout the body so the virus can spread easily and quickly within us. A virus is not a cell, but protein surrounded by a spiky outer skin called an envelope.
Bacteria, on the other hand, are much larger. They live on surfaces of the body or inside the body. Bacteria replicate themselves so they usually stay in one place. It is not until they multiply greatly that they spread to other areas, typically by entering the cells or bloodstream. Bacteria do not replace the cells duplication mechanism. Bacteria have a cell wall and can survive and reproduce on their own. They even have a little tail which helps propel them around.
Because viruses enter and take over the invaded body cells, there are no treatments for them. Bacteria are more ‘surface dwellers’ on cells. This distinction is what allows bacteria to be treated with antibiotics. Viruses have no cure but rather vaccines are developed that prevent the virus from entering the cell. Antibiotics do not treat viruses.
The coronavirus is so new that it had not been discovered until late 2019. Therefore, it was not classified until it received the classification of COVID-19. The CDC (Centers for Disease Control) gave this new or novel virus the classification of CO for corona, VI for virus and D for disease. The number 19 indicates the first year of discovery of this specific virus.
When this virus first came about, there were risk factors that were noted. It is important to point out that these risk factors indicated who might have more severe compilations if they contracted the virus than others. Unfortunately, this concept was misunderstood. Many people interpreted the risk factors to mean those who could contract the virus, not severity of illness. So, people wrongly went about their business thinking they were safe. In reality, everyone has an equal chance of contracting COVID-19.
Early information indicated that children were less likely to contract COVID-19. We now know that this also was a false assumption. There is even evidence that the COVID-19 virus was around months before anyone knew about it, especially in children.
Children do contract COVID-19 so far at a lesser rate than adults. This could be due to many factors. Children have more colds than adults. If the virus is like other corona type viruses, they could have some immunity. Children are around less numbers of people so their exposure could be less. Even their immune systems could react differently to this specific virus. The reason for less numbers of COVID-19 in the pediatric group will become known later when more data are studied.
The tremendous concern, of course, is some extreme reactions of symptoms in children who contract COVID-19. These extreme cases are not that much different than the extreme cases in adults. It is just that there are fewer extreme cases in children. The question is are the cases the same or is there a different reaction in children due to physiology (how the body works)?
Like adults, any child can contract COVID-19, but children with certain risk factors are more likely to become sicker if they contract it. These risk factors include many of the same factors as in adults: immunosuppression, kidney disease, respiratory problems including asthma, cystic fibrosis and pulmonary fibrosis, solid organ transplants, obesity, heart disease, sickle cell disease, diabetes (Type I and Type II), high blood pressure, and liver disease. I have pulled out the issues that children might have. The full list is located on the CDC website.
Children with spinal cord injury are especially susceptible due to being immunocompromised and having inflammation within the body. Most people are surprised to hear both situations exist after SCI. The immune system is compromised because SCI affects the autonomic nervous system (ANS) or the part of the nervous system that works body functions automatically. These are things like your heart beating, breathing, your liver working and all the internal functions that occur without thinking about it.
The ANS controls the body’s response to invaders such as bacteria or viruses. Either the ANS cannot recognize the invasion or cannot mount a defense quickly enough. Since COVID-19 is a new virus, the body does not have a defense to put into action. Inflammation is the body’s natural response to injury both inside and outside of the body. Internal inflammation lingers long after a spinal cord injury occurs.
You can see the immune system working if you get a cut on your finger. The body responds by sending fluid to cushion the injury and natural antibodies to fight infection. The same thing happens within the body when there is an injury such as SCI. This response is controlled by the ANS. When a virus enters the body, the ANS cannot respond effectively for protection.
Symptoms of COVID-19 are some or all the following:
- Fever Cough
- Sore throat
- Fast breathing
- Shaking with chills
- Muscle pain Headache
- Loss of taste or smell
Symptoms of COVID-19 particularly in children include some or all the following:
- Fever that lasts several days
- Belly pain
- Vomiting or diarrhea
- Red, cracked lips
- Red eyes
- Swelling of the hands or feet
- Joint pain
- Vision problems
- Looking pale
At the first signs or symptoms of COVID-19 in your child, call 911 or your healthcare professional immediately. If there is breathing, mental status changes or other emergency conditions call 911. You will be guided through the next steps of testing and treatments. They might want you to observe for a while. More likely, you will be directed to take your child to a testing center. Since your child has a spinal cord injury, most likely they will tell you to go directly to the hospital. No matter what, don’t make these decisions on your own. Immediately call your child’s health professional or 911 and let them direct you as to how to proceed. Everyone needs medical direction in this decision. Delay can bring disastrous results.
Your child may have a positive COVID-19 test. Exposure in children can be up to four weeks prior to symptoms. The carrier of COVID-19 may or may not show any symptoms. You might not know who spread the disease.
If you feel your child is in danger, call 911. Again, do not hesitate. COVID-19 can move rapidly through the body. Emergency care is needed if the child has breathing problems, is confused or dizzy, is sleepy, or has chest pain, has cold, sweaty, pale or blotchy skin. Struggling to breathe or being out of breath that affects talking or movement, turning blue or fainting are more signs to call 911.
When you see children affected by COVID-19 on TV, you are seeing the most severe form of the disease. Many children, like adults, have far milder cases but still require medical attention. Since your child with SCI has immunosuppression, the worst-case scenario of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19) can be occurring. This diagnosis is made when these symptoms are present: less than 21 years of age with a fever of 100.4 (f) or 38.0 (c) for greater than 24 hours, laboratory evidence of inflammation, requiring hospitalization and two or more organs with failure (heart, kidneys, breathing, blood, stomach and bowel, skin and nerves.) Not every child will have all the symptoms.
MIS-C has many of the same symptoms as Kawasaki disease, so it was not directly linked to COVID-19 right away. Kawasaki disease is different but since the symptoms are similar, it was not originally thought to be MIS-C. Symptoms of Kawasaki disease are: fever, rash, swelling of the hands and feet, irritation and redness of the whites of the eyes, swollen lymph glands in the neck, and irritation and inflammation of the mouth, lips, and throat. With either disease, MIS-C or Kawasaki, your child is extremely ill and needs medical attention. Again, let the health professionals provide diagnosis and treatment. Do not delay wondering or trying to sort it out. Call 911.
Medical treatment for COVID-19 is to treat the symptoms and provide life supporting measures if needed. This is a critical illness. Recovery can be lengthy and will require additional rehabilitation therapies.
If your child has been exposed to COVID-19 they should be isolated, and their health professional notified. Protective measures should be taken at this time by washing your hands, isolating, practicing social distancing and reducing number of exposures. Anyone in your household who has exposures to the outside world should not have exposure to your child.
Children who have breathing difficulty or are under two years should not wear masks according to the CDC. Just hours ago as of this writing the suggestion is for children under 8 years. Check current guidelines from the CDC for up to date mask use in children https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/protect-children.html. This is because if carbon dioxide from breathing builds up in the mask, the child will become sleepy. They may not have the functional ability to remove the mask if feeling sleepy. The parent might think they are sleeping rather than inhaling carbon dioxide which can be fatal.
When wearing a mask as a child or adult be sure the mask fits snuggly around the face. Open areas around the nose, sides or chin leave the respiratory system vulnerable to inhaling the virus. In both children and adults, fit the mask securely but be aware of ‘ear fatigue’. This is a very real concern especially since children come in all sizes. Too tight elastic holding the mask on can pull on the ears which can be painful and possible lead to pressure injury.
It is a very unfortunate time in history but we all must do our part to avoid this horrible virus. It affects everyone’s lifestyle. Socially isolating can be a struggle especially for children. Participation in alternative activities can benefit both the parent and the child. Nurse Linda
Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.