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Caitlin Whyte (Host): Welcome back. You're listening to Children's Health Checkup. Today, we are discussing the physical effects of COVID-19 in children. Throughout the COVID-19 pandemic experts continue to learn more about the disease, including long-term physical effects. During the earlier days of the pandemic, it was believed that children were less likely to experience serious illness. However, it is now known that some children can become severely ill and have significant acute and longterm effects. Joining us for this conversation are two pediatric experts who have dedicated their time on the front lines over the past few years. They're going to discuss what they're seeing in the pediatric population when it comes to the physical effects on children. So without further delay, please welcome Dr. Jeffrey Kahn, Director of Infectious Disease at Children's Health and a Professor at UT Southwestern and Dr. Mia Maamari, a Critical Care Specialist at Children's Health and an Assistant Professor at UT Southwestern.

So I'll start with you, Dr. Kahn. Early in the pandemic, parents took comfort in the fact that children seemed to be less effected by COVID-19 both in number of cases and severity of the illness. Can you explain what we've learned since then? And what is the risk now for COVID-19 and children?

Jeffrey Kahn, MD (Guest): It seems that early on in the pandemic, we were seeing less children getting infected. And that may be because of epidemiological issues and public health issues. Remember we were all locked down and children were fairly secluded, if you will, from the rest of the population, there were no schools and children were staying at home. So the chance of the becoming exposed to somebody with COVID was very low. It was certainly low compared to adults. As we moved through the pandemic, and we started opening up our society, obviously there was a greater chance for children to get exposed and infected. That was true when we entered the Delta wave, which was really sort of late summer, early fall, 2021. Schools were in session and the virus was spreading quite readily in the community.

I think what we learned during the next wave, which is the Omicron wave was the fact that we were seeing a lot more children getting infected and hospitalized. It's not clear why. And again, it may be just an exposure issue. Of course, during the entire pandemic children, less than five years of age were not eligible for vaccination.

So it just may be the numbers just caught up to the younger kids in particular, but it seemed that at least with the Omicron wave, we were seeing a lot more kids. And I think it's more than just an exposure story. There may be something about the virus, the transmissibility of the virus that played a role in us seeing a lot more infections in young children and older children too.

Host: And Dr. Maamari, have you seen any trends in the children that you've seen hospitalized for COVID-19 whether it's age or underlying health conditions or something like that?

Mia Maamari, MD (Guest): Some yes. And sometimes no. Certainly the Delta wave was when we had our largest wave of children with COVID and that was COVID in similar ways that the adults were seeing it with severe lung infection, lung disease, lung failure, and needing the most extreme levels of life support, and unfortunately, even death. The Delta wave was very much the first time that we were experiencing large numbers of those cases.

There are some subtle trends in that we saw a lot of teenagers, saw a lot of teenagers with obesity. Some teenagers had a history of asthma. And we also saw a good number of newborns that needed really high levels of ICU care. Those are the biggest trends that we had really seen. Initially, we were really nervous about patients that have a weakend or a suppressed immune systems.

So kids with cancer, leukemia, or organ transplants, and we were number three, we're going to see a large wave of those kids. And while they did come, they weren't the majority of the kids that we saw. Most children were children that had typically normal immune systems, but we saw a lot of obesity. We saw a lot of children with asthma and we saw a lot of newborns.

And if you think about asthma and obesity, those are very common comorbid conditions, that's a large chunk of children in America. So it's certainly not something that can be ignored. But also not something that is traditionally thought of as the weakened immune system. So that had us pretty concerned because it does leave a lot of children susceptible.

And we also saw with the newborns that tells us that it's, there's probably something also going on how the Moms impact on the baby's immune system is as well. All of the newborns that we had seen were born to moms that were unvaccinated. And so there could be susceptibility there as well. And there were some other interesting trends that we saw around the country and actually around the world, is that there was an uptick in children who were diagnosed with Type 1 diabetes. We haven't found the clear link between COVID triggering Type 1 diabetes. There does seem to be an interesting association, and certainly there will be more questions and more research going into that. And that will potentially elucidate that connection.

Generally, I think it was very easy during the pandemic to think of weak immune systems versus strong immune systems. But I think what we've learned throughout the pandemic is that it's not that simple. A lot of the disease that we saw actually came from dysregulated immune response. And so it's not that the immune system was too weak. It could have just been disorganized. It's easy to have that misconception.

Host: Now we're about two years into this pandemic, Dr. Kahn, what are some of the potential long-term effects of COVID-19 in children?

Dr. Kahn: So as you mentioned, we're just two years in, so we're still gathering information, gathering data, experiencing this as we move along. When we think about long-term effects in children, I think we could break it down to two basic categories. Those children who had COVID, whether it was mild or severe, that would be one category. The other category would be children who had multi-system inflammatory syndrome in children. And I'll defer to my colleague, Dr. Maamari, to comment on that. What we have seen is that most children do pretty well with COVID certainly as Dr. Maamari mentioned, we're seeing a lot of children with underlying comorbidities. And those children tend to take a little bit longer to recover. In that regard, the infection with SARS COV2, the cause of COVID is for the most part, these children recovering from a viral infection of the lungs. But there are small group of children who would seem to have these lingering effects of the COVID infection. And we're seeing a number of these children in our Infectious Disease Clinic. And the complaints are often subjective. Children feel fatigue. Brain fog is a common description. Some children are having chest pain, difficulty breathing, and other sort of subjective symptoms. And, I say quite a few of these kids and from a medical standpoint, we've done pretty thoroughly evaluations on them, which are essentially if turned up negative, but there's something else must be happening here. And if it was just one or two children, well, that may just maybe outliers, but we're seeing this more commonly than we thought we would suggesting that there may be something to this. Now, how long some of these symptoms last. I mean, whether they are going to be real long-term consequences over months or years, we don't know the answer to those questions yet. But I think there's a small percentage of children and the same is true with adults who have these post COVID symptoms that are very, very difficult to explain. And we're just wading through those waters right now and hopefully we'll get a handle on this.

There've been some anecdotal approaches to this, none that seem all that captivating as far as addressing this, or at least treating these types of long COVID symptoms. So I guess more to follow up on that front.

Host: Well, Dr. Maamari like Dr. Kahn brought up, tell us about the multi-system inflammatory syndrome that you're seeing in some kids. And how common is it?

Dr. Maamari: Sure. So MISC much easier to say than multi-system inflammatory syndrome in children, was this really interesting phenomenon that really was first described early on in the pandemic in the spring of 2020. And a lot of the reports really came out of Europe. And what they had noticed is about a few weeks afterinlarge COVID wave in the population, they would see children come in with this constellation of symptoms, including rash, fevers for multiple days, abdominal pain, poor eating, poor appetite, and then needing help with breathing and needing help with keeping their blood pressure up and getting their, their heart to squeeze appropriately. They had related this phenomenon to something that is similar, but not the same called Kawasaki disease. And that disease looked similar at first look and affected the arteries, meaning the blood vessels that feed the heart oxygen. And so those arteries were, are more dilated and the heart was malfunctioning during that time.

And so they saw similarities to this illness, but it, since it was different and it was associated with SARS COV2, the virus that causes the disease COVID it was called MISC at least in the US by the CDC, actually in Europe, they have a different name. It is overall rare. Although after having seen it a few hundred times in our hospital, it it's hard to call it rare.

It doesn't feel rare, but, but it is rare when we do look at the numbers. And if we break down the name MISC, we can kind of think of what it is, but multi-system right. Refers to multiple organs affected at once. Inflammatory meaning that the, the process that is happening is that the body is producing lots of inflammatory molecules and those end up effecting the multiple organs.

And one thing that's not in the name by the CDC of MISC, is that it also this post-infectious phenomenon, meaning that it happens, about a few weeks after a COVID infection and it doesn't have to be a COVID infection that produced symptoms. Some of these kids are completely asymptomatic. Some of them had very mild symptoms.

Some of them never even knew that they had COVID. And the first time that we find out is that they come in with MISC. And we find out that through antibody testing, that they had been exposed to COVID and now they have, they have MISC. A lot of these children ended up needing to come to the ICU. A lot of them needed help with heart function and a lot of them needed help with their breathing, not to the same level as the COVID pneumonia patients.

And so if you want to really simplify things, the quote unquote, regular COVID pneumonia. Those kids needed mainly help with breathing and very little help with their heart. The MISC kids needed some help with breathing, but really their main need for ICU level intervention was help with their heart and their blood pressure. Some trends that we have seen in these kids, similar to what we had seen in the regular COVID, we did see clusters of kids with asthma. We saw clusters of kids with obesity, but the majority of kids with MISC actually had no prior conditions. So it is very difficult to predict who's going to get MISC and who's not going to get MISC. Thankfully, many of these kids recovered in the short term, what remains to be seen is how will MISC affects them in the long-term. These kids had cardiac changes. What does that mean long-term? Is it similar to Kawasaki kids who, when they Kawasaki as children, they can have heart disease earlier than some of their peers who did not have Kawasaki as children.

And so will we see similar things with MISC that's unknown and, and we'll have to see what happens a couple of decades down the road.

Host: Gotcha. Gotcha. Okay. And Dr. Kahn, I'll turn back to you for another discussion of long-term effects. Can you explain the term long COVID. We've heard about it in the news so much. How does that affect children?

Dr. Kahn: Well, I think one of the issues with the term long COVID is that there's really not a very good definition for this disease or for this process. I mean, this is certainly symptoms that seem to linger or new symptoms that seem to develop weeks or months after COVID infection or recovery from COVID infection.

And as I mentioned earlier, these are mostly subjective. So we don't have laboratory tests or laboratory diagnostics or criteria to define this disease. I think we may be moving to an area where we may do some, there may be some very sophisticated biophysical types of assays that potentially can be used to try to define this more concretely, but it is hard to define. Children, we've all experienced fatigue, but your fatigue may be different from my fatigue. What you consider as fatigue may be different from what I consider as fatigue. I mean, some of these, these children we're seeing here are really profoundly different than they were before they had COVID. So there's little doubt that, that this is a real phenomenon.

It's just very, very difficult to define and to describe. Nonetheless, it seems that physically, these kids are doing okay. So there may be some behavioral effects or mental status issues that are playing into this. It's very, very hard to define, but I think it's important to realize that, we throw around long COVID a lot. We throw around that term a lot and it may be a bit overused, but on the other hand, we're seeing these children and it's certainly true in adults who have sort of these long-term challenges after COVID. And we just don't understand it right now. And I think that over the next weeks, months and years we'll have a better idea of what this is all about.

Host: Yeah, understandable. Well, as we wrap up here and COVID of course is still happening. Dr. Maamari, what should parents watch for after their child has COVID and what should they report to their pediatrician?

Dr. Maamari: Again, just to kind of describe the two major ways that COVID affects the children is one, they can have COVID pneumonia and then a few weeks later, then they could have MISC. And so those look different and typically you don't get severe cases of both. You may get one or the other, but we have not seen kids that have had both severly. Certainly in, in pneumonia, you'd want to look for difficulty breathing, lips turning blue, really noisy breathing. For MISC you might look for high fever fever for several days, not drinking or eating, significant abdominal pain, rashes, especially if the rashes is not only on the skin, but also on the eyes or the mouth or the tongue, being confused and not acting appropriately, but really anything else that also is worrisome to the parent or the guardian, they should talk to their pediatrician about

Host: and prevention is always key though. Dr. Kahn, what should parents know about protecting their children from COVID-19

Dr. Kahn: the answer is that we have really effective vaccinations. And this is certainly true for obviously for kids who are vaccine eligible. Those five years of age and older. We as a human population, very, very fortunate that at least two very effective vaccines on a new platform became available late in December, 2020. And that's of course the mRNA vaccines produced by Pfizer and Moderna, and these are extraordinarily effective vaccines. What we've learned about these vaccines is in fact is a very, very good safety profile and an excellent safety profile and an excellent effectiveness profile.

And this is the way to protect your children, if they're age eligible to get them vaccinated. And this is true, you know, we're all familiar with vaccines and, you know, to a certain extent, vaccines are a victim of their own success. People never or very, very rarely seen in the world these days or is there a case of polio?

I would say the vast majority of people in the United States, haven't seen a case of measles. Smallpox has been eradicated, and we can go down the whole list of vaccine preventable diseases. And in fact, vaccines are probably the greatest achievement in medical history. And now we have these two vaccines that are and actually a third, Johnson and Johnson that are very, very effective in preventing infection.

And as these new variants emerge, we found that these vaccines were effective in preventing infection, perhaps a little less so than the original strain, but still very, very effective in preventing severe disease and hospitalization. The number one message to parents would be get your children vaccinated, if they're vaccine eligible. Number two would be, if you have children who are less than five years of age, or you have anybody in your household who is particularly prone to infection or immunocompromised or on immunosuppressive medications, make sure that everybody in the family, in the household is immunized.

That's the best way to protect this. This is the cocooning effect that we talk about. You immunize everybody around a susceptible individual. So that would be message I would have for parents. Now, we don't know where the pandemic is going. We don't know whether there's going to be new variants. We don't know whether there's going to be another wave.

And as we move through this, and we may have to adjust our behaviors and our approaches accordingly, but right now, the best thing you could do to protect your children is get them vaccinated.

Host: Always a good note to end on getting that vaccine. Well, Dr. Kahn, is there anything we missed? Any last words you want to leave for listeners?

Dr. Kahn: It's been a long stretch, obviously. We're, we've been at this for over two years now. We're approaching a million deaths in this country. It's just, the numbers are just staggering. I mean, we hope that the current trends are going to continue and that the numbers are going to continue to decline, but the COVID virus is going to be with us.

We're not going to eliminate it. And for sure, we're going to have to deal with this in the future. It may not be these wide, broad outbreaks that go through the country or go through many countries around the world. It may be that there are more regional and local outbreaks of the virus, but we're going to be dealing with this virus from here on.

And hopefully not to the intensity that we experienced over the last couple of years, but it's not going away. We have to be prepared for it. I know there's a lot of fatigue out there and, and understandably so, but I think it's, important that we don't ignore it, that we react to it as the pandemic ebbs and flows, that we react to it it accordingly.

And there are certainly are groups that are working on modifying the existing vaccines, so that they're more targeted towards the variants that are existing right now, though, the initial vaccines are still very, very effective. So they're going to be new developments. We're going to have to react to these developments, but I'm hopeful.

And the other thing I should mention is that there are now drugs, oral drugs that can be given on an outpatient basis for individuals who can't get the vaccine or don't respond to the vaccine or who happened to get vaccinated and get sick. We're collecting a lot of tools in our toolbox to address COVID and we should certainly take advantage of all those tools as we move through the pandemic.

Host: Absolutely. And Dr. Maamari same question to you. Any final thoughts or things we missed as we wrap up?

Dr. Maamari: I could not agree more and I could not stress this more about how, how important vaccines are, how extremely well they've been studied and how they've been studied independently. And the same results have been shown over and over and over again, which is the best you can do in science and medicine.

They are so safe and they are incredibly effective at reducing hospitalization, severe disease and deaths. And it's become really hard to watch children be ill from something that is potentially highly preventable. And so if there is anything I can stress again and again, it's that I would not underestimate the virus. It can harm children. It has harmed children and we can't always predict who will be affected or how they'll be affected. No one is invincible. And again, don't underestimate the, the vaccine. It is safe. It is effective against hospitalization and severe illness and death, and MISC, we'll always do our best to help your child in the hospital and in the ICU.

The ICU is the last line of defense. And so if there's anything that can be done before getting to the last line of defense, we highly, highly, highly encourage it. We really do want to decrease the amount of illness that children go through. And then as you said, earlier, prevention is always better than treatment.

Host: Well, thank you both so much for your time today for this critical information. And of course everything you've done, especially over the last two years to keep our children safe. And thank you, of course, for listening to this episode of Children's Health Checkup, you can find more information at children's.com/COVID-19.

I'm your host, Caitlin Whyte. Stay well.