'No scientific evidence so far to suggest the possibility of a third Covid-19 wave mainly affecting children'

Dr Dhanya Dharmapalan, a consultant in paediatric infectious diseases, Apollo Hospitals, Navi Mumbai and Covid-19 Task Force Member of Apollo Hospitals and the Indian Academy of Pediatrics. Photo; Dr Dhanya Dharmapalan

Even as Mumbai citizens and state officials are in the middle of dealing with the second Covid-19 wave, they are also preparing for a third wave, expected a few months from now. While the first wave largely affected the elderly, the second spike impacted many who were in their 30s and 20s too. There is speculation about how the next wave could possibly affect more children.

On May 23, paediatricians had their first online meeting with Maharashtra Chief Minister Uddhav Thackeray to discuss ways to protect children in the third wave. They suggested including the influenza vaccine in the national immunisation programme and also administering it as a precautionary measure before the monsoon. This would help to avoid confusing flu symptoms with similar symptoms of Covid-19, and prevent them from landing up in hospitals. Additionally, children's mental health is also being discussed. The state paediatric task force has chalked out a plan to help children deal with the mental health issues that may arise from the overwhelming news they hear because of the virus. Separately, the Brihanmumbai Municipal Corporation (BMC) had earlier instructed every jumbo centre in the city to allocate 250 beds as a part of the paediatric ward. The Covid-19 hospitals will also have a certain number of beds reserved for children.

Dr Dhanya Dharmapalan, a consultant in paediatric infectious diseases, Apollo Hospitals, Navi Mumbai has been in the thick of things since 2020 as she is also a Covid-19 Task Force Member of Apollo Hospitals and the Indian Academy of Pediatrics. Mid-day.com reached out to the city-based paediatrician to understand whether children are susceptible to the virus, should it be a cause of concern and how can the influenza vaccine help.

Here are edited excerpts from the interview:

Many have been discussing the possibility of a third wave that may predominantly affect children. What is the global evidence on this, and how susceptible are children going to be to Covid-19 going forward?

There is no scientific evidence so far to suggest the possibility of a third wave predominantly affecting children. The percentage of children accounting for total COVID-19 cases has not differed significantly in the two waves of COVID-19. ICMR recently stated that children accounted for 4.2 per cent of all COVID-19 cases last year while this year it was 5.8 per cent. As total numbers of COVID-19 infected cases go up, proportionately the cases of children go up. The majority of infected children either show no symptoms or have mild symptoms.

As per UNICEF (March update), children constitute 0.3 per cent of the total 2.3 million COVID-19 deaths in 78 countries. However, it warns that child deaths could overall increase due to the indirect effect of the continued pandemic such as poverty, malnutrition, lack of health services owing to an overburdened health system and lack of access to regular immunisation. Brazil had reported a higher death rate, the majority occurring in infants/those with comorbidities and poor access to health care.

Moreover, the virus needs to bind to what are called ACE receptors to cause illness. In children these are less in the lungs compared to adults, therefore children are mostly spared from the severe lung involvement seen in adults. So, parents need not fear. However, administrative preparations to improve paediatric health services to combat COVID-19 are welcome.

What are the risk factors for a severe Covid-19 in children?

Having said that, majority of children suffer mild illness, the risk of severity is in children who have underlying health problems like liver/heart/kidney disease or those who has weakened immune system due to cancer therapy or diseases like HIV or who are obese/with severe malnutrition. Therefore, these children need close follow up.

Rarely, few children develop a life-threatening complication called MISC (Multisystem Inflammatory Syndrome in Children) which usually occurs 3-4 weeks after a COVID-19 infection. These children present with high fever for over 3 days with red eyes, red lips, severe pain in abdomen or loose motions or rash over the body. However, it can be treated when diagnosed early.

Some experts recommend that parents should give their children the influenza vaccine as a precaution, ahead of the monsoon and the expected third wave. Is this advisable and have parents started bringing in children for the shot?

Influenza virus, unlike COVID-19, can cause severe illness in children below 5 years of age and in those who have chronic health disorders like heart disease/lung disease etc. Therefore, though this vaccine is not available in the National Immunisation Schedule, the Indian Academy of Paediatrics has recommended this vaccine from 6 months onwards for several years for the children with risk factors mentioned above. Since Influenza season coincides with monsoon, annual shots are commonly given at this time.

As Influenza (a different virus) is also transmitted through droplets, COVID-appropriate behaviour like mask, hand hygiene and social distancing is Influenza preventive too. But all children are not at risk for severity of Influenza nor does the vaccine against Influenza offer any added protection from COVID-19. Therefore, it would be inappropriate to say that all children need to get vaccinated against Influenza.

If the influenza vaccine is set to be administered in the next few weeks, mothers and children will have to visit the hospital. Given the current situation, does the benefit of the flu vaccine outweigh risks of going out to a clinic/hospital?

As mentioned, the benefit of Influenza vaccination is for those who have higher risk for severity of Influenza. So, there is no need for parents of all children to panic and crowd the hospital for the vaccine. This may itself cause higher risk for transmission of COVID-19. But the regular immunisation must go on and parents should preferably schedule their appointments with their doctors and children above two years must also wear a mask and all keep safe distance.

What are children infected with Covid-19 generally treated with?

Many children do not show any symptoms and therefore do not require medicines. Treatment for over 98 per cent cases is given as per symptoms like paracetamol for fever, cough syrups or ORS for hydration. There is no role for antimicrobials like Azithromycin/Ivermectin/Hydroxychloroquine or Favipiravir. The few cases with moderate and severe cases or those with MISC are treated in the hospital with intravenous medications.

What are the precautionary measures that parents can take now in general?

Children should be taught to wear a mask properly and not touch the outside of the mask which is the most contaminated part. They should be taught to sneeze into the corner of the elbow and wash hands after coming home. Parents should act as role models for their children because children are not expected to follow if their parents themselves do not follow COVID-appropriate behaviour.

Under all circumstances, the grandparents in the house and those with co-morbidity should not be given care of the child if one of the parents gets infected by COVID. Even if the child has no symptoms when parents get infected, the child may be asymptomatic or may develop mild symptoms later and may transmit infection to grandparents who have higher severity risk.

COVID-19 infected mothers can continue breastfeeding following precautions like mask and hand hygiene.

How can children build their immunity to avoid the possibility of being infected by the virus? Any changes to diet that you recommend?
Children must eat a normal balanced diet and drink plenty of fluids. They should avoid becoming obese to avoid higher risk of severity of COVID-19. There is no need for any particular change in the diet specific for COVID-19 or artificial nutrient supplementation.

Children have had to stay largely at home and on the screen. How has it affected their physical and mental health? What recommendations would you make so that children can have a balanced life in lockdown?

Mental health problems have emerged as a bigger challenge in children with many showing signs of anxiety, depression, mood swings. Parents need to talk to their children regarding COVID -19 but it is important to give age-appropriate information. They must understand that children are also stressed with online classes, the inability to go to play with friends. Many children might be anxious regarding their future. Parents must spend more time listening to them and allay their fears if any. It is important for parents to control their emotions and remain calm. Loss of close family members needs to be delicately handled and if required, take professional support.

Avoid a lot of screen time, make them indulge more in constructive and recreational activities. Even in a situation of lockdown, physical activities like exercise/skipping etc can be encouraged inside the house.

The indirect impact of mental health problems due to the continued pandemic for children and for the children of poor families -- the miseries of loss of education, poverty, malnutrition, forced child labour, domestic violence, loss of either or both parents, reduced access to regular child health services is the larger elephant in the room.

Will there be a need for children to be given the Covid-19 vaccine in the near future?

Yes. Though children are not common sufferers of severe COVID-19, they can easily transmit the infections to others. Research has shown that small reductions of duration of virus shedding by vaccination can help in reducing the onward transmission of the disease. Therefore, safe and effective vaccines in children can help towards safe school attendance in addition to individually protecting the children. Children with chronic illness who have high risk factors for severe COVID-19 need vaccine protection. The single dose intranasal COVID-19 vaccine (under trial) has a promising potential to block the virus transmission due to its local action in the nose. Also, since it is needle free, it would be easy to give in children.

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