Early on in the pandemic, it seemed as if kids were spared the worst effects of the coronavirus. But in May, a mysterious illness that affected children and appeared to be linked to the virus emerged. As parents now look to send kids back to school and day care, how should they think about these risks? What do we now know about this new syndrome?
James Hamblin and Katherine Wells are joined on the Social Distance podcast by the staff writer Sarah Zhang to discuss. Listen here:
What follows is an edited and condensed transcript of their conversation.
Katherine Wells: Sarah, we have gotten so many questions from listeners about kids and coronavirus. And they’re often in two parts. One is: What’s up with the disease and kids? And two is, therefore: How are we supposed to think about child care and schools? We can start with the actual virus. A listener named Liz wrote us back in May:
I am a mom of a 3-year-old, 19-month-old, and seven-week-old. I am a nurse anesthetist returning to work on June 1. Can you tell me how worried I should be about this “Kawasaki-like” illness that may (or may not) be associated with COVID-19?
Sorry, Liz, that we’re getting to you late, but maybe we could start there: Sarah, can you just give us an overview of what we know about kids and the virus?
Sarah Zhang: It was clear pretty early on that kids don’t seem to get very sick from the virus. And when they do, they’re often asymptomatic or very mild, and it also seems like they don’t really spread it. But a few weeks after the virus first peaked in New York, doctors started noticing, as Liz says, this Kawasaki-like disease, which is now called multisystem inflammatory syndrome in children, or MIS-C. When I was reporting on it back in May, it had a different name, but I guess they settled on MIS-C.
Wells: It seems like it’s just “miscellaneous.”
James Hamblin: It is the perfect word, actually. I don’t mean to make light of this—because it can be very serious and I’m sure that wasn’t unintentional—but it fits really well.
Wells: Okay, so this miscellaneous syndrome affects children. Sarah, what is it?
Zhang: Well, it’s fittingly a miscellaneous set of symptoms. It includes a bunch of different things that are usually seen with an overactive immune system, like rashes on the palms of your hands and the soles of your feet, a swollen tongue, cracked lips, in some cases really, really low blood pressure. It looks like a bunch of different things that can sometimes happen with different viruses as well. Kids sometimes just have what looks like an overactive immune system. They have almost a delayed reaction to the virus.
Part of the reason this took a while for doctors to notice is that it seemed to peak about six weeks after the COVID-19 cases actually peaked in New York. It seems like there was some delay between exposure and actually getting this syndrome. That’s why it took so long to notice. It’s also because it’s really, really rare.
Hamblin: I think part of the reason we haven’t heard more about it is because it’s so difficult to define and because of that lag. That is why you’re just now seeing these clear cases. The CDC has warned parents to consult a doctor “right away” if their child develops “symptoms of MIS-C” that include “fever, abdominal pain, vomiting, diarrhea, neck pain, rash, bloodshot eye, [or] feeling extra tired.”
And there have been fatalities. Some kids have had serious cases. So essentially, CDC was telling people: Hey, if you don’t have enough to worry about already, if it seems like your kid is feeling extra tired, they might have this serious condition.
Zhang: As you’re saying, it’s this collection of symptoms that are so nonspecific. Part of the worry is that we really don’t know why most kids are totally fine after getting COVID-19 but a very, very small number seem to develop this serious condition. And that kind of uncertainty, of knowing this can happen but not knowing who it will happen in, makes it really hard.
Wells: So this is happening to kids after they have recovered from COVID-19?
Hamblin: They probably didn’t even get it.
Zhang: Yeah, they never had the coughing or the shortness of breath that most of us associate with COVID-19.
Wells: Got it. But these are in instances where they had the virus circulating in their bodies, they fight off the virus, and then some number of weeks later they start to have these inflammatory symptoms.
Zhang: Yeah, exactly. It’s like the virus is gone or almost gone, but the system is still reacting to it for some reason.
Wells: I understand that a lot of the worst reactions in adults to coronavirus happen with a cytokine storm, like an overreaction of the immune system. Is the same theory in play here with kids?
Zhang: I think in a general sense that is what we’re seeing. You fight off the virus first. Even when adults have this really strong reaction, it’s toward the end of infection and they may not actually have that much virus.
Wells: It’s a delayed reaction.
Zhang: Yeah. The real difference is that you just never got the respiratory symptoms in kids that you tend to see in adults.
Hamblin: I’m imagining a sort of Venn diagram here. There’s an MIS-C–COVID-19 Venn diagram where some people are going to have both, some people are going to have just the respiratory symptoms, and some people are just going to have a delayed immune response.
Wells: Are there any theories about why this is happening? Are kids’ immune systems a lot stronger in general, so they’re better at fighting off that initial disease but then keep going too long or something?
Zhang: There are some theories. Kids’ immune systems are stronger and weaker in different ways. Kids tend to encounter a lot of new pathogens because everything you encounter as a kid is new to you, so they tend to be better at fighting off something that’s completely new.
But if you’re seeing something for the first time, it also takes time for your immune system to mount that response. If you’re an adult and you’ve had, for instance, chicken pox before, the next time you see chicken pox, your immune system will recognize it and start getting rid of it right away, whereas in kids, it may take a while for their immune system to respond. So they do work slightly differently and that might help explain why their responses are so different to adults.
Wells: Got it. You know, there was this thought at the beginning of the pandemic that maybe kids are better off and maybe they don’t seem to get sick, so we don’t have to worry about them. But is the lesson here that, actually, we do?
Hamblin: I think kids are better off than adults—though it does seem that they can transmit the virus, as anyone who’s carrying it can. And MIS-C is pretty reliably treatable so far. It shouldn’t be super scary. What is worth keeping in mind is that these patterns are just now emerging. We don’t know how this is going to play out in the long term across the population in terms of potential delayed effects.
Wells: What does this mean for schools and day care? Many parents have been working from home and trying to take care of their children. There are parents who need to go back to work and need child care for their kids. How worried should people be about transmission in these spaces with kids?
Zhang: Well, everyone’s risk calculation is different, but I don’t think this miscellaneous disease is the biggest thing to worry about. You mentioned transmission. Kids bringing it home from schools and day cares, or infecting teachers, is probably a slightly bigger worry. But the evidence does indicate that kids don’t usually get very sick and they’re not walking virus bombs.
Wells: Really? We don’t think that kids are as good at transmitting the virus?
Zhang: Yeah. There haven’t been very many cases where a kid went to school, got sick at school, and brought it back. Part of this is that a lot of schools have been closed. But in the Netherlands, where they have opened schools, they followed families and there haven’t really been any cases where the kid brought it back to the family.
That doesn’t mean it doesn’t happen. And when it comes to risks, there’s no one-size-fits-all advice. It depends on who else is in your household, how old are your other kids, are you living with grandparents. I think the individual family situation matters a lot more than should this day care be open?
Hamblin: I think this is a good moment to resist the impulse to stratify risk or to help people calibrate anxieties in any way other than saying, “Here’s what we know right now and here are some possibilities for the ways this could unfold.” It’s not something to panic about, but it is something that we want to keep a close eye on. I want to be assured that there are not other manifestations of this multisystem inflammatory process that don’t linger and cause something that is actually significant that we aren’t yet picking up on.
Wells: Sarah, you’ve been following the science of the virus since the beginning and covering science for years. What do you most want to know about how this virus works?
Zhang: The question I most want to answer is why it seems to manifest differently in different people. And I think the answer to that actually may not be about the virus itself, but actually in our immune systems, because lots of viruses are really different from person to person. If we could in some way predict who would get really sick once they get this virus, I think that would help a lot in figuring out how to minimize the impact.