We’ve heard a lot about the risk of COVID-19 spread in school-aged children, but what about younger kids?
by Rachel Lane PhD, RD
August 18, 2020
When our city confirmed their first COVID-19 case, my family of three – two career scientists and our 7-month-old son – locked down, motivated by a nefarious encounter with an “every man down” flu-lapalooza a few weeks earlier. After nearly five months, we – like so many families – are wrestling with the long-term costs and benefits of routine decisions, namely childcare.
This discussion is separate from the question of how to open schools safely. It isn’t generally acceptable for school-aged children to crawl around on the floor swapping chew toys all day, but this has been my son’s favorite pastime for at least half his life. In an environment with predictable spit sharing and diaper changes, how at-risk is my 1-year-old son for contracting COVID?
As a scientist, I like to make data-driven, evidence-supported decisions, so I dove into the literature to find answers to my questions:
1. How likely is my child to contract COVID-19 and to spread it to me or someone else?
2. What symptoms and disease severity should I expect for his age group?
3. What is unknown about COVID-19 that hinders my ability to make a “eyes wide open” decision?
This first thing to note is that, because COVID-19 is a relatively new disease, there isn’t a lot of data to drive my decision. The most informative studies reflect cases from early in the pandemic and mainly report on patients in Italy and China.
Will My Kid Catch COVID? If They Do, How Likely are They to Give It to Me or Someone Else?
The CDC reports that COVID is mainly spread from an exchange of respiratory droplets: an infected person breathes (through their mouth and nose), releasing virus-infected liquid that an uninfected person then inhales (through their mouth and nose). This is why masks are so important! We protect others – especially more vulnerable populations, like young children – when we wear them.
The CDC also issued this guiding principle, “the more people children interact with, and the longer that interaction, the higher the risk of COVID-19 spread.” Children too young for school are generally not appropriate for masks, are more likely than other age groups to directly exchange saliva (their closest competition likely being love-ravenous teens), and spend 8+ hours together at daycare in a classroom with about 9 other peers and caregivers. That combination of factors suggests that daycare is a high-risk environment for COVID-19 spread.
So how likely is another child in my son’s class to have COVID-19? Children <1 year old are underrepresented within the US COVID-19-positive population. Although this age group comprises 1.2% of the population, they represent less than 0.3% of all COVID-19 patients. Initially, I was concerned that the low overall disease prevalence in this age group could indicate underreporting, due to a one-year-old’s inability to complain about subtle symptoms, such as fatigue. This concern was offset when I read that 15% of all pediatric COVID-19 cases are children <1 year old. This information indicates that compared with children 1-18 years old, children <1 year old may be at an increased risk for being symptomatic COVID-19 patients, but compared with the general population (of all ages), they are at a decreased risk for contracting the disease.
I was also encouraged by a publication from June. The authors reviewed 131 studies on COVID-19 in children and found that fever and cough are the most common symptoms of COVID-19 infection in this population. New safety procedures implemented by daycares should help identify children with these symptoms to reduce the spread of COVID-19.
Interestingly, the same study found that ~19% of children with a COVID-19 infection don't show any symptoms of infection (they're "asymptomatic"). Another report in the Journal of the American Medical Association this week reported that the viral load of asymptomatic patients is similar to that of symptomatic patients. Effectively, asymptomatic patients are just as likely to spread the disease as those with symptoms. So although new safety protocols reduce the risk of disease spread, asymptomatic kids will be just as contagious as symptomatic children in (and out of) daycare.
Disease Severity in Infants
A May review article in the European Journal of Pediatrics concluded that the infection may less severely affect children (ages 0-18) than adults, as evidenced by a mortality rate of 0.08% in this population. For perspective, the reported one-week mortality rate for US COVID-19 patients of all ages during the week ending on August 1st was 7.8%, down from 12.6% the week prior. These data suggest that if my son does come down with COVID-19, he is unlikely to die from it, which does provide me with some solace.
We Will Know More Tomorrow
At first, COVID-19 symptoms were reported to be “flu-like,” but as time passes, we discover more and more about this disease that adds to the mystery: survivors report symptoms – including neurological complications, such as decreased alertness – that progress for months, and autopsies of the deceased provide evidence that COVID-19 affects the heart and brain. Profound lingering symptoms do not necessarily correlate with initial respiratory disease severity. How will I evaluate the presence of some of these symptoms in my son who hasn’t started talking and won’t have the vocabulary to explain symptoms for several years to come. How could lingering neurological symptoms affect his development?
Listen to the Expert
I firmly believe in trusting the trained experts around you, so I asked my son's pediatrician – a weathered, stoic physician with decades of experience and a well-established practice – what he thought about COVID-19 risk and daycare. He focused on the positive. “The protective measures that daycares are taking will probably mean there is less overall disease spread [in daycares] this year than in previous years” was his basic message. He also reminded me that comparatively, there are many other diseases children pick up at daycare that are potentially much more serious.
Prioritizing Isn’t Simple
Family priorities and flexibility further complicate the decision process, positioning us between a rock and a hard place: do we choose socialization or sanitation? Mental or physical health? Can we accommodate a 2-week quarantine (or multiple quarantines) if a child in the classroom tests positive for COVID-19? Can we function without childcare? Each family’s answer to these questions will look different.
The Decision Continuum
While I’m still uncertain about the best childcare solution for us, this process has made me feel a little more comfortable encouraging social interactions for my son, especially now that he is one year old. We implement a few guiding principles for those interactions: we maximize outdoor social opportunities and avoid high traffic situations. Friends join us at the neighborhood pool (first thing in the morning to avoid crowds) or for a walk at the botanical gardens. Our playdates involve one friend at a time, instead of groups.
The right answer will look different for everyone, and the initial solution doesn’t have to be permanent. I have a feeling "the right choice" will evolve over time, creating a decision continuum, where our solutions reflect expanded knowledge, understanding, and opportunities. In these uncertain times, embracing flexibility is key.