Throughout the COVID-19 pandemic, which has raged in the United States for just under two years now, the devastating impact of the virus on adults and the elderly has been front and center, but what is the virus’s impact on children and teens? Is COVID-19 always “mild” for children and teens? And where can we find the latest medical guidelines concerning COVID-19? 

To learn about how the COVID-19 is affecting children and teens, I interviewed Dr. Geetanjali Srivastava who is a pediatric emergency medicine physician and the medical director of Valley Children’s Hospital in Fresno, California. Valley Children’s is one of the largest children’s hospitals in the country, serving about 1.3 million children and adolescents in the Central Valley of California, and over 100,000 children visit their emergency department each year. Dr. Geetanjali went to medical school at McGovern Medical School in Houston, did a three-year residency in pediatrics, and then a three-year fellowship in pediatric emergency medicine. She also has a Master’s Degree in Public Health with a focus on healthcare policy. 

Author’s Note: Dr. Geetanjali was interviewed in late November 2021 when the Delta variant was the dominant strain of COVID-19 in the United States. This interview was edited for clarity. 

Niraj: There’s a common understanding that COVID-19 poses very little risk to children, do you think this is an accurate view? 

Dr. Geetanjali: Do children get affected by COVID-19? Absolutely. Do they get critically ill? A very small minority do. But if someone asked me if COVID-19 is the most dangerous infectious disease for children in the United States, I would say no. There are other diseases that are viruses that would be more dangerous. In a normal year without COVID-19, more children die of the influenza virus than they are of COVID-19 if that puts it in perspective. [1]

Niraj: When children are severely ill with COVID-19, what does it present as? 

Dr. Geetanjali: So there are two main types of illness caused by COVID. We have acute COVID-19 just like any other infection: you get the virus, and within a few days, you have symptoms such as cough, fever, congestion, and pneumonia. And we are seeing more children affected by acute COVID-19 with the Delta variant than we did during the original wave of COVID-19. And commonly these children had comorbidities; obesity was one of the most common comorbidities as well as diabetes. The children we saw in the ER with acute COVID during the second wave were definitely ill and a lot of them went to the intensive care unit. 

The other syndrome, the MIS-C—which stands for multi-system inflammatory syndrome with COVID—is a uniquely pediatric disease. And we saw that during the first wave of COVID-19. It is an inflammatory response that occurs about four to six weeks after acute infection with COVID-19. So it’s not the COVID-19 virus that’s problematic with MIS-C—it’s your body’s reaction to the latent virus.  

Niraj: Are there any risk factors for having MIS-C? 

Dr. Geetanjali: So we’re actually studying that. Our hospital was part of a multicenter study looking to see why some children had MIS-C and why some people were completely asymptomatic and totally fine. We don’t know the answers yet, but we do think you have a genetic predisposition to have a very over-reactive inflammatory response to certain viruses. We do not know what really is a risk factor at this time. We did see that people of color had a higher incidence of MIS-C and that could have just been because people of color were getting COVID-19 at higher rates. [2] 

Niraj: To have MIS-C, do you have to have had severe COVID-19? 

Dr. Geetanjali: No, and that’s what is so interesting. If we actually asked the parents of some children with MIS-C, they often said their child was sick for maybe a day or that their child was asymptomatic and they found out they had COVID-19 because they had been exposed. A lot of times these families didn’t even know their child had COVID because they had such a minor response to the initial virus, but then six weeks later, they were critically ill. Some of the parents were in denial and couldn’t believe that their child’s illness was associated with COVID-19, even after we did all the blood work and were enrolling them in studies.  

Niraj: What are signs that a parent or caregiver should take their child to the hospital if they think they have COVID? At what point do you know you need to take your kid to the ER? 

Dr. Geetanjali: So that’s a really good question because it’s really hard to know the difference between a regular virus, like the common cold virus, versus the COVID-19 virus. One of the symptoms that sets apart COVID-19 is air hunger or having shortness of breath, such as the inability to walk from one part of the house to the other or just getting winded very quickly. With a lot of viruses, you’re kind of tired and not feeling good, but you don’t get winded. So shortness of breath is a big component of acute COVID-19. And if your child is having a fever and happens to be a little overweight, that puts them at higher risk of severe COVID. 

I think it’s always better to check either with your own physician or urgent care or the emergency department if you have any concern that their oxygen level might be low. You can now buy pulse oximeters at CVS, Walgreens, or your local pharmacy. I actually don’t know how accurate they are, but I know for adults, they are being used quite a bit for patients to monitor themselves at home after discharge from the hospital. So I think there are some really good quality pulse oximeters—I’m not saying that everyone should buy one, but that’s something to consider if this pandemic goes on and on. [3] Pulse oximeters may be something we’re all going to have like thermometers.  

Niraj: So if your child has shortness of breath and COVID-19 symptoms, is that the point you take them to the ER, or do you first check in with a primary care physician? 

Dr. Geetanjali: We always say check-in with a primary care physician, but unfortunately, most primary care physicians aren’t going to see you in person if they think you at all could have COVID-19. They might do a telemedicine appointment and will probably end up referring you to the emergency department. But I always say you could be very lucky, and you could have a physician that would see you, saving you and your family a long wait in the emergency department and also the risk of exposure to other diseases you just don’t need or want.  

Niraj: What would you say to people who are unsure if they want to get vaccinated or are unsure if their children should get vaccinated? 

Dr. Geetanjali: I think as we always say: discuss it with your physician. Hopefully you trust your physician—that’s why you see them or you take your kids there. I think discussing with them their personal experience about their patients and themselves or their families and why they’ve chosen to protect their families is important. I think that’s definitely something that’s closer to home, but as usual with anything else in medicine, especially in the US, I think going to the CDC website is an excellent place to get more information. With going to social media or other types of information, you just can’t validate where the information is coming from, and there’s a lot of false information. And I would say go to sources of information like the American Academy of Pediatrics, the American College of Emergency Physicians, and the Infectious Disease Society. These are organizations that are hundreds of years old and have a whole history of providing good, solid, scientific information for the laypeople. They’re there to protect you, and they’re there to protect the physicians and nurses and healthcare personnel. So you have to look for organizations that have always been there and always provided information to keep people safe.  

Niraj: What is the CDC and who works for it? 

Dr. Geetanjali: It’s a pretty large governmental organization. It is comprised of scientists, physicians, researchers, epidemiologists, nurse practitioners, and public health nurses. It’s a whole wide network of people that do scientific inquiry—all aspects of it—from policy development to implementation to communication. The CDC stands for Centers for Disease Control and Prevention, and its goal is to control and prevent the spread of diseases. Even when there’s no epidemic, that’s what they do every year, such as with influenza, HIV, measles, and any other infectious disease. Their job is to keep the public safe. 

Niraj: What are some aspects of COVID-19 that puzzle you and that you want answers to, especially concerning children? Because it’s a disease we still don’t know a lot about, and it hasn’t been around for that long. 

Dr. Geetanjali: Absolutely. I think understanding why people are asymptomatic and others aren’t is really interesting: why is one person completely asymptomatic while another person that looks very similar, maybe of the same ethnicity or same age, is so sick? What is it about Person A versus Person B? We are curious about this with most diseases, but with COVID-19, it has been extremely obvious. In such a short period of time, you see the different responses people have to the same virus. So I think figuring out the risk factors that we don’t even understand is crucial. We definitely know obesity is a risk factor, but there are so many other risk factors we don’t know. Definitely with the Delta wave, I’m seeing a lot more teenagers that don’t have risk factors being really affected. I had seen this one kid who was eighteen, and I knew really quickly when I saw him that he had COVID-19. But he had been through so many different adult hospitals and had been misdiagnosed because he didn’t have any risk factors. 

I definitely want to figure out why certain kids get MIS-C because those kids were very, very ill. They all ended up having significant cardiac abnormalities from the virus, with inflammation of the heart and coronary arteries. We’re following ninety of those kids long-term with a cardiologist. It’s been about a year we’ve been following those kids, and most children are doing quite well and aren’t having prolonged cardiac abnormalities which we thought could have been permanent. So there is some good news when it comes to MIS-C.  

Niraj: How long is the typical hospital stay for a child with severe COVID? 

Dr. Geetanjali: I don’t know, actually. I kind of lose track once they leave the emergency department, but I would say with pneumonia, probably several days, not too long. If they’re critically ill and they go straight from the ER to an intensive care unit, I think you’re looking at about a week. But I think if they’re stable enough not to go to the intensive care unit, you’re probably looking at two to three days. Again, this is just a personal experience based on the patients I’ve admitted.

Niraj: What is the mortality rate for children with acute COVID at your hospital? 

Dr. Geetanjali: I would say less than one percent. I can count the number of deaths we’ve had from acute COVID-19 which is great. 

Niraj: Is that pediatric mortality rate consistent across the country? 

Dr. Geetanjali: Yes. The mortality rate is very low in pediatric acute COVID-19. MIS-C has a higher mortality rate than acute COVID-19, but it’s still very low.  

Niraj: COVID for the last couple of years has been dominating public and medical attention, so what are other public health issues that are alarming you as well?

Dr. Geetanjali: One thing that I think is breaking all of our hearts in pediatrics is we’re seeing a horrible, horrible epidemic of behavioral health in adolescents across the country. [4] A lot of teenagers were affected adversely during COVID-19. They were isolated, and I think some of them were a lot more on social media, so they internalized a lot of it—the loneliness and depression. Some of them really got into using substances. In my twenty-plus-year career, I’ve never seen such sad teenagers at a very young age. I’ve seen ten and twelve-year-old kids come in severely depressed and still trying to manage their trauma from isolation. And I think it was pretty traumatic for children to be ripped away from their friends, from their teachers, from all their social activities, from sports—things that they really wanted to do and excelled at. I think the consequences of the isolation really show the difference between the people that have socioeconomic means and the ones that don’t. For example, some people were very fortunate to have really high bandwidth on their WiFi to be able to do Zoom while others didn’t. So I think more and more we will discover how COVID-19 really affected people differently depending on their means. 

Footnotes:

[1] The CDC reported that 1,015 children under 18 years old died due to COVID-19 in the United States as of December 2021. According to the American Academy of Pediatrics, about 0.00%-0.01% of all child COVID cases resulted in death as of February 3, 2022. 

[2] According to the CDC, MIS-C disproportionately affects certain racial and ethnic groups, including non-Hispanic Black and Hispanic children and teens. Recently, Dr. Geetanjali noted that based on her personal experience, MIS-C appears to be much less common with the Omicron variant compared to incidence with the original strain of COVID-19 or Delta variant. 

[3] A pulse oximeter is a painless medical device that is clipped onto a finger to measure the oxygen content in the blood and pulse rate. These metrics can be used to monitor the health of a patient infected with COVID-19, especially if they are at high risk of developing severe disease. The quality of over-the-counter pulse oximeters is often less accurate than those used by hospitals, but they can still be good indicators for when oxygen saturation falls below normal. If you are at risk for severe COVID-19, you can ask your doctor for their opinion, and they may prescribe a medical-grade pulse oximeter.

[4] According to the CDC, the proportion of mental-health-related emergency department visits between April and October 2020 rose by 24% for children 5-11 years old and 31% for children 12-17 years old compared to the same period in 2019 in the United States. The CDC also reported that between February and March 2021, suspected emergency department visits for suicide attempts among 12-17-year-old girls increased by 50.6% compared to the same period in 2019 in the United States. Read this declaration about the national emergency in child and adolescent mental health.