As Britain appears to be on the brink of a second wave of coronavirus, children, once again, seem set to pay a high price. Just two weeks into the start of the academic year, hundreds of schools have been forced to close or send whole year groups home because of pupils testing positive.
Nurseries are reportedly sending toddlers home at the first sign of a cold. Last week, as the testing crisis grew and frustration among parents boiled over, head teachers warned they were preparing for schools to run part-time.
Six months since the WHO declared Covid-19 a pandemic, confusion remains over how the disease affects children – and how easily they can pass it to others. So, what do the experts know so far?
How many children catch coronavirus?
Children accounted for just one in every 100 cases of Covid in England during the first wave of the pandemic, according to statistics from Public Health England.
However, on Friday, the Office for National Statistics said that Covid cases in children are on the rise, with infection rates among two to 11-year-olds now seven times higher than they were in July.
Shiranee Sriskandan, a professor of infectious diseases at Imperial College London, is studying the role of children in spreading coronavirus. “Some antibody studies, which indicate evidence of previous infection, suggest children are just as likely as adults to have been infected,” she says. “While other studies show that they are less likely to have been infected – perhaps half as many as adults – the truth is probably somewhere in between.”
Age seems to matter. In a South Korean study, children younger than nine years old accounted for just 1 per cent of confirmed cases, whereas children aged between 10 and 19 accounted for 5.2 per cent of cases.
What seems certain is that when children do catch Covid, the risk is extremely low. “Reassuringly, for children there is an abundance of evidence that the disease is mild,” Prof Sriskandan says. It's a point illustrated by the following graph, which shows how the risk of hospitalisation from Covid increases with age.
A study published in the British Medical Journal last month, which analysed two thirds of all patients admitted to hospital in England, Scotland and Wales with Covid-19 between January and July, found less than 1 per cent were aged under 19. Six of these patients died, all of whom had severe underlying health conditions.
How can I tell if my child has it?
Most cases in children are asymptomatic. For those that do have symptoms, the NHS says children present with the same symptoms as adults – a high temperature, a new or continuous cough and a loss of smell or taste.
However, this may be misleading: data from the UK-based Covid Symptom Study app, run by King’s College London, has shown that more than half of children who tested positive did not log any of the three classic adult symptoms. Instead, 55 per cent had fatigue, 54 per cent had a headache and almost half had a fever (as you can see in the table below). Sore throats and skin rashes were also common. A separate study, published this month by researchers at Queen’s University Belfast, found that vomiting and diarrhoea were more signs of the disease than a cough.
Should I send my child to school with a cold?
The problem for parents, and a major driver of the huge demand for testing in the UK at present, is that the advice remains to keep a child away from school, self-isolate and get them tested for Covid-19, if they develop a fever or cough. Experts stress, though, that sneezing and a running nose is not a symptom of coronavirus – and, indeed, that symptom suggests it is very likely to be just a cold.
Tim Spector, a professor of genetic epidemiology at KCL, who analyses data from the Covid Symptom Study app, told the BBC that children with runny noses should not be tested.
There is no official requirement to keep a child with a cold off school. If your child has a runny nose and no coronavirus symptoms, it is up to you whether or not you send them to class.
How likely are children to spread Covid?
The answer to this vital question remains unclear. “It’s been hard to work this out because children seldom have symptoms – so there may be silent transmission,” says Prof Sriskandan.
Research by Berlin’s Institute of Virology suggested that while children might have milder symptoms than adults, they still had the same levels of the virus in their bodies. However, a study that analysed the source of 31 household clusters in China, Japan, Singapore, South Korea and Iran found that children were the source of infection in just three of these cases.
Emily Oster, a professor of economics at Brown University, who analyses data on Covid at explaincovid.org, says: “If your little kid has Covid-19, there seems to be only about a 5 per cent chance you’ll get it.”
Why don’t children spread coronavirus? One theory is that children tend to breathe out with less force than adults, and closer to the ground; another is that it is simply down to the fact they don’t tend to get a cough as part of their symptoms, meaning transmission is reduced.
“It could also be because the receptor for the virus causing Covid-19 is present only in low amounts in children, so the virus can’t attach and set up an infection in children’s respiratory systems as easily,” Prof Sriskandan says. “Or because there are other illnesses that affect adults more than children, which might interact with Covid-19 to make it worse.”
Should we hug our grandchildren, if they are showing no symptoms? In Switzerland it’s OK for grandparents to get cuddles; but experts in the UK are less keen. Grandparents are advised to keep a one-metre (3ft) distance (as impractical as that is with children under five). “The reality is, we simply don’t know, so the risk of close contact with children … is difficult to tell,” Prof Jonathan Ball, an expert in emerging viruses from the University of Nottingham, says.
Dr Sanjay Patel, a consultant in paediatric infectious diseases and immunology at Southampton Children’s Hospital told The Telegraph last week: “I would not have my children hugging my parents, who are both over 70, at the moment.”
How can schools stay open?
In June, mathematic modelling by a team from the University of Warwick found that a gradual reopening of schools was unlikely to lead to a second wave, while researchers in Seoul found no sudden increase in cases among children aged 19 and below in the two months after schools reopened.
But the Warwick study did caution that “there is noticeable variation between the regions of the country”, and that has played out: there have been school closures even in the first month. Prof Sriskandan says an increase in cases is inevitable, “because there is more general movement of people ... more teachers have to come in to work, parents and guardians come to the school gate – and opening schools enables people to get back to their usual workplace”.
The guidance is that if a pupil or staff member has a suspected case, classes continue, but if there is a confirmed case, pupils in their bubble could be told to self-isolate.
Many schools have, due to limitations on space and resources and government requirements, made whole year groups “bubbles”. Last week, a school in Swansea sent home 455 sixth formers, as well as teaching staff, after one pupil tested positive.
Despite these challenges, Prof Sriskandan believes that whole year bubbles may be the best solution for older children as the disruption caused by splitting them into smaller bubbles would be too great.
Dr Michael Tildesley, a mathematician at Warwick, who develops models to simulate the spread of zoonotic diseases, believes the risk of coronavirus spreading around schools is low. “This disease has a relatively long incubation period, so it’s likely these [latest] cases were infected before they started back at school,” he says. “We haven’t seen outbreaks within schools. But in the next few weeks we’ll have a much stronger idea.”
One concern is that worried parents are keeping their children away even if they feel well – official figures show only 88 per cent of pupils were back at the start of term.
As a father of school-aged children himself, Dr Tildesley says parents should not panic: “The risk of being out of education is massive, whereas the risk of children getting seriously ill is low.”
What is Kawasaki Disease, the new coronavirus-related 'syndrome' which a small number of children have presented with?
By Eleanor Steafel
Back in April, NHS doctors were told to look out for a rare but dangerous reaction in children.
This was prompted by eight children in London becoming ill, including a 14-year-old who died. They were hospitalised with similar symptoms (including a high fever, rash, red eyes, swelling and general pain) that initially looked like sepsis. Some of those patients tested positive for Covid-19, prompting conversations in the medical community about whether there might be a new inflammatory syndrome which could be an extreme reaction to Covid among very young patients.
Some of these cases have been likened to a rare inflammatory heart condition called Kawasaki, for which the symptoms are similar to sepsis and toxic shock.
“For doctors looking after these children, they present as if they’ve got sepsis,” explained Dr Patel. “They’ve got a fever and abnormal blood tests, but when further investigation is done they recognise that there’s also an inflammatory component that is affecting bits of the body – you can get a rash, or red eyes, or cardiac inflammation.”
These symptoms have been likened to the overactive immune response known as a "cytokine storm" which has been seen in adults with Covid-19. In these cases, it seems it is the body's immune response rather than the virus itself that proves life-threatening.
Dr Patel said there are some similarities between these pediatric cases and what has been observed in a number of adult cases, but it’s too early to say for sure. “The timing and dynamics are not exactly the same. So in adults, you often have seven days of Covid symptoms and then you potentially get worse and that’s when the cytokine storm happens.
“The timelines are not quite so clear with this. It may be a similar phenomenon but at the moment it’s just too early to say, we’ve got too few patients with this to draw any firm conclusions.”
It's important to note that these cases are very rare events.
Is this only happening in the UK?
At the start of May, three children in the US were also being treated for inflammatory symptoms thought to relate to coronavirus. All three – who range in age from six months to eight years – had fevers and inflammation of the heart and the gut.
Dr Patel said a small number of these new cases have been identified in Europe too. “We’ve been talking to Italian and Spanish colleagues and they have had extremely small numbers of something similar – this inflammatory presentation in children. But still we haven’t been clear if it’s due to Covid.
“Half the children have tested negative for Covid on our viral testing, so there’s still so much to learn.”
When should I dial 999?
The RCPCH (Royal College of Paediatrics and Child Health) advises you should go straight to the nearest A&E department or call 999 if your child...
- Becomes pale, mottled and feels abnormally cold to the touch.
- Has pauses in their breathing (apnoeas), has an irregular breathing pattern or starts grunting
- Experiences severe difficulty in breathing, becoming agitated or unresponsive.
- Is going blue around the lips.
- Has a fit or seizure.
- Becomes extremely distressed (crying inconsolably despite distraction), confused, very lethargic (difficult to wake) or unresponsive.
- Develops a rash that does not disappear with pressure (employ the ‘Glass test’).
- Has testicular pain, especially in teenage boys.
How can I treat my child’s mild coronavirus symptoms at home?
If your child is well enough to be looked after at home, experts at RCPCH recommend that parents treat symptoms of fever or pain related to Covid-19 with either paracetamol or ibuprofen.
The Commission on Human Medicines’ Expert Working Group on coronavirus has now concluded that there is insufficient evidence to establish a link between use of ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs), and the worsening of Covid-19. Catrin Barker, Chair of the RCPCH Medicines Committee and Chief Pharmacist at Alder Hey Children’s Hospital, says: “Our advice to parents is that either paracetamol or ibuprofen can be used to treat their child if they have symptoms of Covid-19, such as fever and headache, and should follow NHS advice if they have any questions or if symptoms get worse.”