'It's Not The Time To Let Up': MGH Pediatrician Has The Answers On Kids With COVID

With the delta variant, children are more likely to get COVID-19 when they're exposed, but it's not more likely to put them in the hospital, said Dr. Vandana Madhavan, the clinical director of pediatric infectious disease at Massachusetts General Hospital (MGH).

But the pandemic's health effects on children aren't limited to just getting ill from COVID-19, Madhavan said: Childhood obesity is rising, and kids are missing check-ups with their doctors and other routine vaccinations. While she emphasized that this is not the time to let up restrictions, she encouraged families to evaluate activities like seeing relatives in terms of "safer" versus "less safe": in a pandemic, interactive activities aren't completely safe.

Mary Blake: Let's start with your broad assessment. Where are we in this pandemic? And I know there have been a lot of concerns about under 12. What types of patients do you see? What's your general sense? And then we can kind of delve into other things.

Dr. Vandana Madhavan: Yeah, of course. You know, there's been a lot of media attention about the absolute number of cases of children who have acute COVID-19, who are in the hospital and even requiring ICU care. And I think it's important to remember that it's, unfortunately, not surprising that we are seeing more absolute numbers, because we're at the point where, you know, especially in Massachusetts and in New England, we have higher vaccination rates than in other parts of the country. And because of that, and because obviously kids under 12 can't be vaccinated at all and vaccination rates for the 12 to 17 year olds are, you know, less than you know for adults at this point, the percentage of children among that unvaccinated pool is obviously going to be higher. We know that with the delta variant, it's more highly transmissible and therefore it's going to more easily spread among that unvaccinated pool, without vaccinations to kind of stop the severity of infection, to stop the spread to other people. And therefore, we're going to see more children and in the absolute numbers.

And at the same time, while we are dealing with delta variant, we're dealing with a more open community than we had at earlier points of a pandemic this summer. More people traveled, more people did activities with their children, there's been more social gathering, et cetera. And so it's been a perfect storm, so to speak, with children being more likely to be in that pool of unvaccinated individuals, to be more likely to be exposed and then be exposed to a more transmissible variant.

But at the same time, it's important to remember that a particular child is still not at greater risk for hospitalization or for ICU-level care than in the past. The percentage of kids requiring hospitalization remains in that, like, 1 to 2% range, and it has not increased over the course of the pandemic. So while the absolute numbers have increased, remembering that overall we are seeing the same patterns of severity, that this is a virus that, even with all the mutations, still is affecting older people proportionally more than than the little ones.

Blake: I just find that this is something that the media is not reporting. I'm hearing report after report that says the numbers are increasing across the country. They don't give us specific numbers, they don't relate that to you said more because of the delta variant. But again, kids aren't getting as sick as older people. Where do you think this disconnect is? Why is there such a sense of panic, in a way? And I may be overstating it, and I don't mean to put that word in your mouth, but as you said, it's important to know, but is that message getting out and why?

Madhavan: I think it's because, I mean, children are, for the most part, healthy. We think about happy, healthy children going to school, going to their activities — and a child in the intensive care unit, or even in the hospital, is obviously a much more rare event than an adult. And so I think that even when I think it's easier to focus on the, “Oh, my goodness, look it, look at these numbers, there are more children in the hospital,” versus delving into the math, really looking at the denominator and looking at why we're seeing more kids. Basically, if you're a child and you get sick, you're not at more risk of being admitted than you were before. You're just at more risk of getting sick to begin with — because of the delta variant and because things are more open right now.

And I think that springboards into the other message that I really want to make sure that families and parents and the general community keeps in mind: is that, yes, we're all so sick and frustrated with the fact that we're still living with the pandemic, but we are still living with the pandemic. It's not the time to let up, it's not the time to say, "Great, we're done with this, we can go back to where we were" right now, and continue emphasizing all of the different tools that we have.

It's not enough to say, "Oh, great, the adults are vaccinated, everyone else will be fine." At this point with delta, no. We need more people vaccinated. We need more adults vaccinated because of delta being more transmissible, we need more teenagers to be vaccinated and we need to get the kids vaccinated as soon as they're eligible.

And at the same time, being mindful of wearing masks indoors, being mindful of what activities we engage in, remembering what's safer. I always focus on safe-r versus safe. We're in the middle of a global pandemic, we can't say something is 100% safe, we can always think about safer. So outdoors is better than indoors. Smaller gatherings are better than large, you know. And thinking about that, and really emphasizing what is important for your family. That travel might be important because you're visiting grandparents who are sick and you haven't seen in two years — versus, you know, another family who has decided to prioritize a particular activity after school.

Blake: Do you see the patients — and I guess we're really talking about 12 and under, the not-yet vaccinated — are you seeing that there are preexisting conditions, or are you seeing the perfectly healthy? Because also the media is looking at older adults and saying, "Okay, these are people, perfectly healthy and they're getting sick: some are dying. How about kids? And then I also wanted to ask about the actual death rate. Kids are getting sick, they're in the ICU, but are they dying?

Madhavan: Unfortunately, the death rate is not zero, but the death rate has not increased over the course of the pandemic. And in terms of preexisting conditions, we do know that obesity is a big one, and certainly more so in the teenage age group than the younger ones.

But again, even though we are still worried about children with preexisting lung disease, and heart disease, neurologic disease, et cetera, as having the potential to have worsened disease, we really aren't seeing the same patterns that we do with, say, influenza, where we absolutely see the kids with asthma or congenital heart disease, et cetera, having worse outcomes — requiring hospitalization, requiring increased levels of care. We're not seeing that with COVID-19.

Blake: The other thing I just wanted to ask: Pediatrician at MGH, are parents concerned? Are they looking for a reassurance? Are they frightened? I know it varies from from family situation to family situation, but in a general sense, what are you seeing from your patients and then their parents?

Madhavan: I think it's information from a reliable and trusted source. I think over the last 18 months, we've had so much information thrown at us. And I think one thing is to keep it in context, that no one knew about SARS-COV-2 two years ago. And the enormous amount that we have learned over the last 18 months is breathtaking, that we've been able to learn so much about best practices in terms of treatment, in terms of developing a vaccine and getting that vaccine out, learning about preventative therapies of monoclonal antibodies to prevent worsening of disease after someone is sick.

There's been so much that we've learned that everyone, not just parents, everyone is under information overload. And so I think parents, especially right now, are like, "Okay, let me like regroup, let me focus on my family. What do I need to do? Like, what do I really need to focus on? What do I need to make sure our family emphasizes moving forward to make sure we can get our kids back to school, keep them in school and have them have some return to a normal childhood?" Because clearly childhood has been upended in the last 18 months.

Blake: Yeah. Do you see that reflected in kids, too, that there is just such confusion?

Madhavan: Yeah. I mean, kids are ecstatic to be in school and realize that even they can see their friends. You know, it's hard, but they're really looking towards their grown-ups: their parents, their other family members, their teachers, other trusted adults in their lives to provide that reassurance and that structure.

Kids thrive on structure — much as we think kids want to rebel against order and structure and routine, they really thrive on that as well, and they want to know that, "Okay, yes, my routine might be different, but my parents are telling me about this, we're all wearing masks when we go inside, we're all doing this." And knowing that their routines might be new, but they're routines, and it's providing them structure — and that's what the kids want.

And the parents want to make sure that they're doing the right thing for their children, like parents have always wanted to do, but right now, when it seems like the world is shifting so often, they're really wanting to make sure that they're doing the right thing for their children.

Blake: Is MGH involved in a study in terms of when the vaccine might be available for under 12? Or any of your patients, or is MGH involved in that at all?

Madhavan: MGH is a site for the Moderna trials currently, enrolling younger kids as well. I've certainly referred patients to that. A lot of families are asking, "Hey, I heard Boston might be a site, maybe even MGH, I'd love to get my kids involved." And so there's definitely interest because I think a lot of us know that, to move this forward and to move beyond the pandemic and to get to the point where SARS-COV-2 becomes an endemic virus and it's a virus that we live with — just like so many other viruses — requires us to have more people eligible for the vaccine and more people vaccinated.

I mean, my kids are 10 and 8, so I'm right to go with all of the families who are eagerly awaiting more information.

Blake: But just in a general sense, how many from MGH, do you know? Is it a large-scale study, do you know, are there dozens of kids, hundreds of kids?

Madhavan: That's a great question, I actually don't know. I'm not directly involved in the vaccine studies. So I've referred patients there. As you may be aware, the FDA wanted 3,000 more young kids in both the Moderna and the Pfizer trials, and so the numbers have increased, but I don't know about specific enrollment at each of the sites.

Blake: Anything else that you want to add? I've been wanting to have this kind of conversation. I really love the way you put it in a format that people can understand, because I think a lot of people, as you said — a lot of information is out there, and trying to get that information, the proper and the science and what people really need to know, can be a challenge.

Madhavan: Absolutely. I think I just want, again, people to come back to the fact that, while we are at a better place than we were a year ago — and certainly 18 months ago, we know so much more. We know what works, what doesn't work. We know that masks work. We know that outdoor transmission is something we don't have to worry about at the same level as indoor transmission, certainly. An outdoor, crowded music festival is one thing, but generally speaking, going outside, going to the park is safe. We know that we don't need to quarantine the mail, we don't need to wipe down groceries.

But I think coming back to families and kids, we just know so much more about how to keep kids safe in school and in the vast majority of their activities. And that's what we really need to focus on. You know, kids work at school, and we need kids to be at school, in person, with their peers. We've just seen so much disruption in kids' lives. While they're not as directly affected medically as older adults, the social disruptions, the educational disruptions, the effects on mental and behavioral health, access to safety-net resources for families at risk, just so many other things.

The rates of obesity are increasing in children, children aren't getting their routine care and are falling behind in vaccines in many parts of the country, you know, there's so many other disruptions to childhood. And so it's really important to keep doing what we know is working to get to the point where we're all in a better place.

Blake: Gotcha. One last question: do you feel that the whole game will change? Is it a game changer, when the under-12 are vaccinated?

Madhavan: I think it will be a huge step forward, because that's a large percentage of the population that's going to be vaccinated, it's going to allow us to get closer — and perhaps reach — the level of herd immunity that we need to stop delta.

That said, if we see a slow rollout of vaccines and a slow rate of uptake in that younger age group, it just allows the virus more time to mutate, and we're going to deal with more mutations in the virus that might make it even more transmissible. And so we just have to be mindful of that, that it's not, like, "Great, vaccines are available" — people have to get the vaccines, they have to get them in a timely manner, while getting vulnerable adults their vaccines, the immunocompromised adults their boosters, getting the teenagers the vaccines. Continuing to move forward with efforts in all the other age groups as well.