The Centers for Disease Control has recommended that children between the ages of 5 and 11 get the Pfizer Inc.–BioNTech SE’s COVID-19 vaccine. Although some parents have rushed to bring their children to hospitals, pharmacies and pediatricians’ offices to get them vaccinated, not all are convinced that the vaccine is safe or necessary.
A recent Kaiser Family Foundation survey found that 33 percent of parents are taking a “wait and see” approach, but 30 percent say they have their minds made up and will definitely not get their young children vaccinated against COVID-19.
Dr. Ronald Kleinman, Physician-in-Chief at Massachusetts General Hospital's MassGeneral for Children, believes this is a mistake.
“The COVID-19 vaccine is the best way to protect everyone from severe illness and death and allow a safe return to many pre-pandemic activities by helping to curb community transmission," says Kleinman. "For children who have experienced great insecurity about whether they, their parents, siblings and loved ones will become infected — and what will happen if they do — the protection and freedom to go to school, see their friends and participate in activities without fear have been a long time coming. For children who live with the added burden of insecurity over having enough food or safe housing, relief from the additional crushing toll COVID-19 has taken on their lives and their families is essential.”
Here, MassGeneral for Children’s Pediatric Infectious Disease Clinical Director Vandana Madhavan and Primary Care & Population Health Management Director Alexy Arauz Boudreau address parents’ questions on everything from why everyone who can get vaccinated should to how to keep unvaccinated kids from getting sick at school.
We’ve heard that kids don’t get the same severe disease adults do. Is that still true? Why is vaccinating children important?
DR. VANDANA MADHAVAN: Evidence continues to show that most children who have COVID-19 experience mild to moderate cold-like symptoms. Many kids have no symptoms at all.
Most kids who get sick will only require supportive care such as fever medication, fluids and sometimes supplemental oxygen. For severe cases, there are other treatments. Monoclonal antibodies can control the inflammatory cascade that causes pneumonia and other complications. The antiviral remdesivir helps decrease the viral load by keeping the virus from replicating. Several newer medications that interfere with the ability of the virus to replicate are likely available very soon. Doctors prescribe the steroid dexamethasone for patients who have had the infection for several days and developed lung inflammation.
However, children who aren't initially sick can experience serious illnesses. Due to the relative increase in pediatric COVID cases, we are seeing more children requiring hospitalization and intensive support. Some can experience longer-term complications, including multisystem inflammatory syndrome in children (MIS-C) and 'long COVID.' This is significant. We are losing more children to acute COVID than we have to influenza.
What is MIS-C?
DR. ALEXY ARAUZ BOUDREAU: MIS-C is an inflammatory reaction in the body that occurs about four weeks after infection with the SARS-CoV-2 virus. Most cases are preceded by a positive COVID test though not always. The initial symptoms — often including fever, rashes, red eyes, diarrhea and vomiting — may worsen over a few days. The inflammation can affect the heart, blood vessels and other organs and require urgent care. Children 5 to 9 tend to be most vulnerable, but 1-year-olds have also been affected. The most significant number of cases have occurred among young adults between the ages of 18 and 29.
From October 1, 2020, through November this year, the CDC has documented over 5,526 cases of MIS-C in children. Over half of those are Latino and Black non-Hispanic patients; 48 patients with MIS-C have died.
We know that the COVID-19 vaccines are effective. We also know that the dangers of COVID-19's acute and long-term effects for children are more severe than the risks of the vaccines' very rare side effects.
What factors should I weigh when deciding whether or not to vaccinate my child against COVID-19?
DR. ALEXY ARAUZ BOUDREAU: It’s important to weigh the risks and benefits to the individual and the community. We know that the COVID-19 vaccines have been extensively tested, are highly effective and very safe. We also know that the dangers of COVID-19's acute and long-term effects for children are much more severe than the risks of the vaccines' very rare side effects.
DR. VANDANA MADHAVAN: Also, vaccination doesn't just prevent acute COVID complications that may require hospitalization and ICU stays. Vaccinations prevent MIS-C in children, teens and young adults, and they also guard against long-term COVID symptoms and provide excellent protection against the variants.
Are there any dangers to vaccinating my younger child against COVID-19?
DR. VANDANA MADHAVAN: The press coverage of the FDA's June 25 warning about the slight risk of myocarditis after the second dose of the Pfizer and Moderna COVID-19 mRNA vaccine did generate concern. Myocarditis is an inflammation of heart muscles that can cause chest pains, shortness of breath and increased heart rate. It can also be asymptomatic.
A recent New England Journal of Medicine study of males between 16 and 29 years of age estimated that 11 of every 100,000 studied developed myocarditis a few days after having been fully vaccinated. The absolute risk is still very small, and studies have shown that Covid-19 is much more likely to cause heart problems than the vaccine does. If hospitalized, most young myocarditis patients stayed but a short time; the vast majority recovered without any complications.
How concerned should I be about my child getting infected with COVID-19’s Delta variant?
DR. VANDANA MADHAVAN: We do not see different symptoms in children infected with the Delta variant than with other strains. As with any other virus, kids with COVID-19 can present with fever, malaise, exhaustion, GI symptoms and classic respiratory symptoms. Nevertheless, the spread of the Delta variant did result in a five-fold increase in COVID-19 hospitalizations among children and adolescents over 6 weeks in late June to mid-August.
DR. ALEXY ARAUZ BOUDREAU: The Delta variant's transmissibility is the concern — especially in areas with low vaccination rates — not necessarily that it's making children sicker or more likely to be hospitalized. This is being monitored closely, though. While the U.S. surge of the Delta variant is beginning to diminish, the rise of a new variant is another good reason to consider vaccinating our children. If fewer people are getting infected with SARS-CoV-2, there are fewer opportunities for the virus to mutate into other troublesome variants.
What are the potential long-term effects for children who get COVID-19?
DR. ALEXY ARAUZ BOUDREAU: We still don’t have enough children who have been affected by long COVID to draw firm conclusions. But we are closely watching cases we have in a clinical study here at MGH and those throughout the country.
From what we have seen, long-term COVID, which presents as new symptoms from acute COVID or ongoing symptoms, can also affect children, although perhaps to a lesser degree than it does adults. Symptoms include persistent cough and shortness of breath, fatigue, difficulty concentrating, diarrhea, palpitations, mood changes, chest, stomach, joint and muscle pains, and they last weeks to months after the start of the infection. The journal Nature reported that up to 10 percent of children under 12 who are infected have symptoms lasting longer than 5 weeks. Treatment may require multidisciplinary support from cardiologists, pulmonologists and neurologists, given all the organs that can be affected.
The CDC strongly recommends universal masking for children in kindergarten through grade 12 and all staff regardless of vaccination status.
Can vaccinated parents give COVID-19 to their unvaccinated children?
DR. VANDANA MADHAVAN: The risk is not zero since we do know that while vaccinations provide excellent protection against the serious consequences of COVID-19 infection, they don’t offer 100 percent protection from infection itself. In the early stages of infection, vaccinated adults can transmit the virus to their children — and any susceptible person. That is why we recommend that anyone 5 years old and up get vaccinated. Once vaccinated, your protective antibodies lower the amount of virus you carry if you get infected, so you won’t infect as many people. But with Delta still the dominant strain in the U.S., we have more to learn.
If I get my child vaccinated against COVID-19, will he or she still have to wear a mask?
DR. ALEXY ARAUZ BOUDREAU: The CDC strongly recommends universal masking for children in kindergarten through grade 12 and all staff regardless of vaccination status. The American Academy of Pediatrics agrees, recommending a multipronged, layered approach to keeping schools safe, including immunization and masking. Here’s why:
- Masking will reduce the chance that unvaccinated children pass the infection on to their classmates and help prevent COVID cases from closing schools
- Masking protects kids’ privacy. Requiring masks is like asking children to wear school uniforms, and it puts everyone on the same level and relieves social stress, especially in middle school
- Masks protect immunocompromised children who can’t develop robust antibody responses after vaccination
- Masks cut down on the transmission of many other respiratory infections, some of which, like the flu, have COVID-like symptoms that would require those students who get sick to quarantine and miss school
- Mandatory masking allows teachers to focus on teaching — not ensuring children who aren’t vaccinated wear masks. As vaccination rates among all school-age children increase and community transmission rates decrease, masking requirements will likely be relaxed
COVID-19 has shone a spotlight on how our society’s inequities affect health and health outcomes. COVID-19 has been more prevalent among Black and Hispanic people, with more frequent hospitalization and long-term consequences and death.
There has been much news coverage about how the pandemic has hit Black and Hispanic people especially hard. How are children in your practice coping with the impact of COVID-19 on their communities?
DR. ALEXY ARAUZ BOUDREAU: COVID-19 has shone a spotlight on how our society’s inequities affect health and health outcomes. COVID-19 has been more prevalent among Black and Hispanic people, with more frequent hospitalization and long-term consequences and death. In addition, Black and Hispanic children are more likely to have a parent or know someone who has died of COVID-19.
Black and Hispanic people also face more difficult psycho-social circumstances. They are more likely to experience financial difficulties due to COVID-19, including food insecurity and housing issues. Internet connectivity issues at home may have made remote learning more difficult for their children, who often attend schools with fewer resources. Finally, income constraints usually mean families can’t afford large homes, making social distancing and shutdowns harder to bear. Two of my patients come to mind: A 10-year-old whose parents were both hospitalized in April 2020 for over a month. His adult sister moved back to care for him, but when she also contracted COVID-19, the child had to become the caregiver. I have another patient in 7th grade whose teacher scolded him for keeping his camera off during lessons. He did so because, with three other siblings at home attending school on Zoom, the bathroom was the only place where he could attend class in relative quiet.
We have spent a lot of time talking about the medical effects of COVID-19 in children. But by far, the psychological trauma inflicted on all children is the most significant consequence, and COVID’s toll on Black and Hispanic children has been unfairly harsh. Human beings can usually adapt to challenging circumstances, and children are incredibly resilient. With the proper support tailored to each child’s needs, this collective trauma can be an opportunity to help children and teens build resilience and move forward.
As part of the COVAX facility, UNICEF is working to deliver 1.4 billion COVID-19 vaccine doses around the world in 2021 — along with treatment and diagnostic kits, masks and hygiene supplies. No one, including children, is safe until everyone is safe. You can help.
Top photo: © Kelly Sikkema/Unsplash