The second wave of COVID is engulfing our country. At the start of the COVID-19 pandemic, reports indicated that the disease was mostly affecting adults. But over the past few months, the number of children who are COVID positive is also increasing significantly. The Maharashtra government’s health department statistics in April highlighted an alarming 51 percent rise in COVID virus infection among children within a short span of 30 days in the state.

This rising case statistics graph reported among children is a trend reported worldwide in the global map. Just one year ago, child COVID-19 cases made up only around 3% of the U.S. total corona cases. But the latest report of the American Academy of Pediatrics, drawn from data collected through April 29, shows that children represented 22.4% of new cases reported in the past week.

There are many reasons for this significant rise in the COVID cases reported among children and adolescents. Relaxation in COVID precautions, social distancing norms and COVID protocols, exposure of children to shopping malls and other crowded places without proper protection gear, the re-opening of educational institutions especially for the conduct of examinations, stark increase in COVID cases reported among pregnant women and rapidly spreading mutant strain (genetically modified) viruses have all resulted in the rapid spike in COVID cases. Fortunately, for the vast majority of the affected children, there were only mild symptoms reported. Among the affected children, only very few are requiring hospital admissions. According to data released by ICMR a few weeks back, among the children admitted during March and the first half of April 2021, in patients who were children in the 0-19 years age bracket constituted only 5.8 percent of the total COVID admissions. This is in comparison to the 4.2 percent in the first wave reported earlier.

The COVID virus can infect children of all ages – from newborns to older children and adolescents.

As per the current knowledge, COVID affects children in three time frames. The first and the most common presentation constitutes the symptoms that appear within a few days of infection which is similar to any other viral illness. The second presentation occurs in a very small proportion of children who were infected and recovered from their initial symptoms in the form of a condition called MIS-C. This occurs three to six weeks after the onset of symptoms of the infection and is more severe. The third is an extremely rare form known as long COVID in children. Here children continue to have protracted symptoms like tiredness, sleep disturbances, and impairment of vital senses like taste disturbances, blurred vision, and abnormal touch sensation even after three months of the initial illness.

There were no significant changes in symptoms reported during the first and second wave of COVID. The most common symptoms include fever, sore throat, cough, and runny nose. Symptoms of vomiting, diarrhea, and abdominal pain are more common in children. A good percentage of children may not have any significant symptoms at all.

95% of children who are COVID positive have only the above-mentioned mild symptoms. Moderate or severe symptoms are very rare among affected children. Let’s see what they are. An important symptom is an increase in the baby’s breathing rate. It is expected to have fast breathing when the child is having a high temperature. Therefore it is important to check the number of breaths per minute after giving paracetamol and confirming that the fever has settled. Respiratory rates in children under two months of age should be below 60, in children between the ages of two months and one year below 50, between one and five years below 40, and below 30 in children above five years of age. If breathing rate is more than this, it will be considered as a symptom of moderate severity. In such cases, the child is likely developing pneumonia.

Severe symptoms include drowsiness, blue discoloration of the fingers and lips, and complete refusal of food and water. Oxygen saturation can be monitored at home with a pulse oximeter (ensure proper recording with good displayed waves). Pulse oximeter readings dropping below 95% is an indicator of moderate to severe disease.

Children with mild symptoms can be managed via home isolation and supportive care, including suggesting proper rest, drinking plenty of water, and monitoring the child’s body temperature at six-hour intervals. If the temperature is above 100 degrees Fahrenheit (38 C), fever can be controlled by administering paracetamol. Children with diarrhea and vomiting should be given ORS solution, salted porridge water, tender coconut water, or other fluids frequently to prevent dehydration. Breastfeeding should be continued. 90-95% of children can be managed at home in this way. Children with moderate symptoms should seek the advice of a medical practitioner, preferably through tele-consultation or face-to-face interaction, to determine further treatment measures including inpatient hospital admission for further treatment. However, children with severe symptoms should be admitted to the hospital and treated immediately.

RTPCR is the most reliable testing method for identifying COVID cases in children as well as in adults. The Union Ministry of Health has confirmed that even mutated viruses can be detected by PCR testing. PCR-based nucleic acid amplification test (NAAT) is also a reliable test option. Rapid antigen test (RAT) is the second option. Even though a positive test is confirmatory, a negative test result needs confirmation by PCR testing if the child is exhibiting COVID symptoms.

Multisystem inflammatory syndrome in children (MIS-C) is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs. This condition typically emerges two to six weeks after a COVID infection or an exposure to a COVID positive family member. The syndrome is rare but can be very serious. The initial symptoms of MIS-C are persistent high fever for four to five days, redness in the eyes and mouth, skin rashes, abdominal pain, and diarrhea.

The largest data on MIS-C was published in April 2021 in a renowned medical journal JAMA by a team led by researchers from the US Centers for Disease Control and Prevention (CDC). In this study, they looked into the distribution and characteristics of 1,733 children diagnosed with MIS-C during a period from March 2020 to January 2021 in the US. Among these children, 90% had involvement of at least four body parts, more than half had low blood pressure, and one-third of them had abnormal heart function. More than half of these children needed admission to the intensive care unit for further treatment. The death rate reported was 1.4%.

The clinical characteristics were similar in various similar studies published from India. A study published in the Indian Pediatrics journal from SAT Hospital, Government Medical College, Thiruvananthapuram in April 2021 examined 32 cases of MIS-C referred to the unit. Children responded well to intensive care support and treatment modalities like immunoglobulins and pulse dose of steroids. An important factor highlighted by this study was that only 6% of children were referred with a suspected diagnosis of MIS-C, highlighting the fact that it continues to be a great masquerader. Also, this could be an indicator that awareness about this relatively new illness is varied among physicians and pediatricians.

The exact cause for this condition is unknown to date but the most accepted hypothesis is that this is an outsized delayed immunological response of the body to COVID-19 infection.

It is now consistently observed that MIS-C peaks 2 to 5 weeks after spikes in COVID-19 cases. So an increased number of children presenting with MIS-C is very likely in the coming weeks and months in India. Our health care system and authorities should gear up to face this increased number of pediatric cases.

It is important to abstain children from being exposed to crowded places, postpone child-related ceremonies and functions, wash and sanitize children’s hands frequently apart from promoting mask-wearing practice and inculcating social distancing practices. As per the recommendation of the Indian Academy of Pediatrics (IAP), masks need to be worn by all children above the age of 2 years. Children who are less than 2 years of age need not use the mask solely due to safety reasons.

Parents of breastfed babies should try their level best to be confined indoors to prevent their exposure to infection. WHO recommends that mothers with suspected or confirmed COVID-19 should be encouraged to initiate or continue breastfeeding. But mothers should take proper safety and health-related precautions including wearing a mask and washing hands with soap and water or usage of alcohol-based hand rub before holding the baby.

COVID vaccine trials have proved to be safe and effective in children between the ages of twelve and fifteen. Canada has approved the use of Pfizer vaccines in this age group. It is expected that FDA approval authorizing the emergency use of the Pfizer vaccine in this age group in the US is imminent. Other vaccine manufacturers are also undertaking trials in children from 6 months of age in different countries.

Routine immunization can be continued 2 weeks after the child is asymptomatic of COVID infection. If the child needs some higher medications such as high-dose steroids, which suppress the immunity of the patient, immunization needs to be deferred for 3 months after the medication as per IAP recommendation.