How to recognize Covid-19 symptoms in children, based on pediatricians’ advice

Are parents really supposed to be reassured by all this talk about “mild” cases of Covid-19 in children? What about the unfortunate “few” youngsters who have died or come down with a strange and severe associated illness?

No parent wants to take the odds that their child might be the exception to the rule.

“We’ve had 90 deaths in children in the United States already, in just a few months,” Dr. Sean O’Leary, vice-chair of the American Academy of Pediatrics Committee on Infectious Diseases, told CNN’s Anderson Cooper on Monday.

“It’s not fair to say that this virus is completely benign in children,” he said.

As a number of schools and universities across the country have begun classes or are moving forward with plans to begin full or partial in-person instruction in the coming weeks, fears among families are on the rise. The question looms: Will our children be safe?

After all, there has already been a 90% increase in the number of Covid-19 cases among children across the US in just the last four weeks, according to data released this week by the AAP.

In Florida, where most public schools haven’t opened yet, seven children have died, three in just the last month. Hospitalizations due to Covid-19 among children in Florida rose by 105% during the same four week time frame, from 213 to 436.

Because most children have been sheltering at home until recently, it’s not surprising that the numbers of cases in children were low at the start of the pandemic.

“Kids just haven’t had that many contacts,” said CNN Chief Medical Correspondent Dr. Sanjay Gupta in a Tuesday Facebook Live event. “As we’re seeing kids develop more and more contacts, we are seeing the numbers go up. And they’re going up at an increasingly rapid pace. This is why I am worried about schools.

“We’ve got to approach this judiciously because if we have terrible outbreaks in schools, and if people get sick — kids, faculty, teachers, whoever gets sick and someone dies — obviously beyond the physical toll, (there is) the psychological toll, as well on communities,” Gupta said. “Which is something that really worries me.”

What are the symptoms?

Symptoms of Covid-19 are the same in children as they are in adults.

“If you look at the long list of potential symptoms — congestion, cough, fever, loss of sense of smell — they can all happen in both adults and children,” O’Leary said.

Other key signs include any difficulty in breathing; a rash, especially one that is quickly spreading; a lack of energy; and problems keeping a child awake, said pediatrician Dr. Daniel Cohen, who practices close to the epicenter of the New Rochelle, New York, outbreak, where nearly 2,900 people were infected from early March through late May.

“It’s very important to let the doctor know immediately if you can’t really get them up, if they’re falling asleep all the time and just exhausted, if they’re not drinking, not eating — the activities of daily living,” Cohen said.

Don’t hesitate to call the doctor

No worry is too small to reach out to your pediatrician, experts say. Parents are the best detectives because they know how their child typically behaves.

“It may be something that you cannot communicate but something’s bothering you,” Cohen said. “I always tell parents, ‘Look, if you’re nervous, I should be, too. That’s just the way things are right now.’ The only call that’s a wrong call is the unmade one.”

O’Leary agreed. If parents “see their child is looking particularly ill or sicker than they would expect with a typical cold or illness, they should call their pediatrician to discuss. Severe anything is always a concern.”

The pandemic is affecting the way medicine is practiced. Take fever, for example, a common sign of illness in children that might have been put on the “watch and see” list in pre-Covid times.

“Today if we have a child with fever, I’m talking to those parents on a daily basis because of the ambiguity and the fear we all have,” Cohen said. “We don’t want to miss that one kid.”

It’s not just the diagnosis of Covid-19, he said. “It’s watching the progression of the illness. Is this child getting sicker faster than you would like to see? And that’s when you want to get them care,” Cohen added.

That guidance applies to the emotional and psychological health of children as well, O’Leary said.

“Kids being more isolated, kids showing more anxiety, more depression,” O’Leary said. “Those are things — even though they’re not directly related to Covid — that need attention.”

Can you tell if your child is sick?

It’s an especially scary reality for parents that many young children are asymptomatic, which means there are no signs or symptoms that their kids are carrying the virus. Still others have an extremely mild case with few issues.

That should be a relief for parents when it comes to their child’s safety, because if a child with Covid-19 is weathering the virus well, pediatricians are just supporting and guiding the parents during the illness, Cohen said.

The concern then turns to protecting others, such as siblings, parents, grandparents and the community.

“Children can be a spark and we don’t want the fire to spread,” Cohen added. “The best way to get rid of a fire is to remove the fuel, so we keep everybody separated.”

The only way a parent might suspect an asymptomatic illness is by tracking their child’s exposure to others with Covid-19 and to be aware of what is happening in the school the child attends.

“Knowing their habits, knowing who they were around, knowing their exposures are key,” Cohen said. “You know, a child not wearing a mask in Georgia is different right now than a child not wearing a mask in New York, because cases are rising in Georgia.”

Whether asymptomatic children should be tested for a coronavirus infection depends on “how often the kids are being exposed to other people” and the testing capacity in their communities, O’Leary said.

“The most important thing for getting kids back into school is really to get the virus under control in the surrounding community,” he said.

Mitigation measures that work for decreasing transmission of the virus — wearing masks, cleaning our hands and physical distancing — are most important, O’Leary added.

Rare but severe illness linked to Covid-19

Another worry for parents is multisystem inflammatory syndrome in children (MIS-C), It’s a rare and unusual presentation in children that can appear a few days to weeks after a child has been exposed to Covid-19.

“It resembles something known as Kawasaki’s, which is also an inflammatory syndrome in the body. And it can be quite devastating for children,” Gupta said.

“Thankfully, it is rare, but it does happen,” Gupta added. “It does seem to happen in the United States, in the UK, more than other countries around the world, and we’re still not sure why that is. But this is something that doctors, pediatricians, parents, everybody is sort of keeping an eye out on.”

As of August 6, the US Centers for Disease Control and Prevention had confirmed 570 cases of MIS-C across 40 states and the District of Columbia, including 10 deaths. The average age of those cases is 8 years old, and 70% of the cases have occurred in Latino or non-Hispanic Black children.

Dr. Kevin Friedman, a pediatric cardiologist at Boston Children’s Hospital, said that although there could be aspects of the immune system that predispose certain groups to MIS-C, the effect on communities of color could also be related to higher rates of multifamily living conditions, parents holding jobs as essential workers outside the home and higher rates of preexisting health conditions.

The clues of this rare syndrome

The first clue to MIS-C is a persistent fever without a clear cause, according to the AAP. If that pops up in a child who has been recently exposed to anyone who may have had Covid-19, it should “raise suspicions.”

Other signs to look for include abdominal pain, diarrhea, swollen glands, red or swollen hands and feet, red cracked lips and pinkish or red eyes, called conjunctivitis. Rapid breathing or other respiratory signs may also be present, but are not as common.

Beside the common fever symptoms, the gastrointestinal symptoms are most prevalent in children with MIS-C, with 80% to 90% of patients experiencing them, said Friedman, who is also an assistant professor of pediatrics at Harvard Medical School.

Children with MIS-C get sick rapidly, the AAP says, and may soon show signs of shock. When examined, they show symptoms of multi-organ dysfunction and high inflammatory blood levels of inflammation.

Most children with MIS-C will need to go to the hospital, the CDC says, and some will need care in the pediatric intensive care unit.

However, experts like Friedman believe there’s a milder form of MIS-C that doesn’t quite surface in public health reporting. “We’re probably only experiencing the tip of the iceberg with this disease,” he said. “Some mild cases are also occurring.”

MIS-C can be prevented the same way we prevent coronavirus spread in general, he added. That means making sure you and your family are washing your hands regularly, complying with universal mask adherence and practicing social distancing.

It’s one more thing to watch out for as kids go back to school, but the condition is still very rare.

“Any place where there is Covid exposure, there will be MIS-C too. It is inevitable that we’ll see this with the reopening of schools,” Friedman said, adding that in his experience the vast majority of children with MIS-C improve and “they improve quite quickly.”

Not sure your child is sick or just stressed?

Some parents may be concerned with more typical parenting issues — like if their child is truly sick or possibly just avoiding getting up early. Because we’re in a pandemic, experts say it’s best to assume the child is not faking symptoms.

“Many kids are having depression or mood reactions to the pandemic, so that can also affect energy level and motivation,” said developmental behavioral pediatrician Dr. Jenny Radesky, an assistant professor of pediatrics at the University of Michigan.

“Similarly, if your child tends to have headaches or stomachaches in response to stress, or has a sensitive stomach, then use that information to help you not overreact to new complaints,” she adds.

After all, we are all storing a lot of stress in our bodies these days. When asking about symptoms, she adds, don’t ask direct questions such as ‘”Does your throat hurt? Does your tummy feel weird?”

“Children will say automatic yes and no responses,” Radesky said. “Instead ask ‘What feels bad? Point to it. What does it feel like?’ “

Finally, remember this: “It’s hard to fake a fever. Fevers are not psychosomatic,” she said. “When in doubt, call your child’s doctor. They know how to differentiate organic symptoms from psychosomatic reactions.”

You still could be sending a sick kid to school

Still, no matter how careful a parent is, “because so many kids with Covid-19 are asymptomatic, it’s certainly still possible that you are sending a child with asymptomatic Covid-19 to school,” Radesky said.

“We need more surveillance testing of asymptomatic students and teachers, otherwise we may feel false reassurance that we are sending a non-contagious child to school,” Radesky said.

In a commentary published Tuesday in the journal JAMA Pediatrics, a Stanford University School of Medicine’s pediatrics team recommended that schools follow a three-pronged testing approach, carried out in collaboration with local hospitals:

• All students with symptoms must be tested;
• Schools should conduct random student and staff testing to identify asymptomatic patients (important for children especially);
• and students from high-risk households should be offered testing more frequently

“As many school districts face budgetary constraints, schools must evaluate their options and identify measures that are particularly important and feasible for their communities,” the authors wrote.