“Kids” and “COVID-19” in the same sentence typically meant a discussion about distance learning. That all changed last week when a 5-year-old from New York City died of a pediatric complication that can present about a month after having coronavirus.
“With each passing day we’re learning more about this terrible virus, and this potentially new development requires even greater understanding,” New York State Department of Health Commissioner Dr. Howard Zucker said last week. “We’ll devote the resources of the department to research each potential case and share our findings with health care providers around the state and country.”
Not only are kids not immune to coronavirus — though the overwhelming majority are asymptomatic or have mild cases — but a very small percentage of the very small percentage of kids affected have recently come down with Pediatric Multi-System Inflammatory Syndrome (PMIS) — also seen as Pediatric Inflammatory Multi-System Syndrome (PIMS) — which can be deadly. PMIS is similar to Kawasaki Syndrome, which following a viral infection in kids can lead the immune system to attack inflamed organs. Kawasaki Syndrome, which was discovered in 1967, still has no known cause.
“This particular illness is not exactly the same, but it has a lot of the same features as Kawasaki disease and probably has a similar cause,” said Dr. Scott Bookner of Scarsdale Pediatric Associates. He added, “It’s the body’s own immune system reacting to having had coronavirus. We don’t know why it happens in some children and why it doesn’t happen in most children.”
On Wednesday, New York State Gov. Andrew Cuomo provided an update on PMIS during a press conference. The state is looking into some 100 reported cases and three children have already died from PMIS: the 5-year-old in New York City, a 7-year-old at Westchester Medical Center in Valhalla and a teenager in Suffolk County.
PMIS presents about a month after infection, so the fact that cases are starting to present now corresponds with the timeline of Westchester, Long Island and New York City being epicenters for COVID-19 during the last two months.
According to a press release from the governor’s office, “Of these cases, 60 percent of the children displaying these symptoms tested positive for COVID-19 and 40 percent tested positive for COVID-19 antibodies. Additionally, 71 percent of the cases have resulted in ICU admission, 19 percent of cases have resulted in intubation and 43 percent of the cases remain hospitalized.”
“We must stay alert with this virus because we’re still learning, and what we thought we knew doesn’t always turn out to be true,” Cuomo said.“When we first started with this virus, we were told children are not affected, which was a great sigh of relief. But now we’re finding out that may not be 100 percent accurate, because we’re seeing cases where children who may have been infected with the COVID virus show symptoms of an inflammatory disease like the Kawasaki disease or toxic shock-like syndrome. New York State has been aggressively investigating these new cases and is leading the efforts on this nationwide and the more we know, the more we’ll communicate.”
Local pediatricians say there is no cause for alarm just yet when it comes to COVID-19 or PMIS in kids.
“It definitely gives people a little bit of pause to be seeing this, but to put the whole thing in perspective, the numbers of kids, at least the percentages, who are suffering from what they are calling PMIS is still very, very low, compared to the number of children who have been infected by coronavirus,” said Bookner, former director of pediatrics at White Plains Hospital Center.
Without widespread testing, there is no way to be sure how many children have had mild or asymptomatic cases of COVID-19 so, when PMIS strikes, it seems out of nowhere for parents.
Dr. Maryann Buetti-Sgouros, the chair of the department of pediatrics at Northern Westchester Hospital in Mount Kisco, goes back to her days as a student at Columbia Presbyterian when well-known rheumatologist Jerry Jacobs imparted a bit of wisdom: “He taught us one thing that I’ve been repeating the past 25 years: If a child has a fever of 104 for greater than four days, they need to be reassessed.”
Since so many pediatric coronavirus cases are almost unnoticeable, Buetti-Sgouros recommends parents chart the oddities in their kids’ lives. A random day or two where they aren’t themselves or feel achy charted in May could be a clue in June that the child had coronavirus as PMIS sends the immune system “into hyperdrive” weeks later.
“I’ve been explaining to people this is kind of like your body going into attack mode after seeing the virus,” Buetti-Sgouros said. “We’re not sure yet if it’s the virus attacking the blood vessels and the organs, or if it is the inflammation caused by the infection. I think Dr. Anthony Fauci said it best when he said, ‘We don’t know what we don’t know.’ We’re learning about it as we speak.”
In addition to the prolonged fever, Bookner recommends looking out for abdominal pain, rash, red eyes or kids who are “just acting sicker than usual.” That’s when it’s time to call your pediatrician so tests can be performed.
The biggest concern for both Buetti-Sgouros and Bookner when it comes to children and COVID-19 is the kids’ ability to spread the virus to others rapidly once they are released back into society and especially when they go back to school, whether that happens in the fall or later on.
“They seem to be doing well against it, however, since we don’t know the actual numbers, they might be asymptomatic spreaders of the virus, which is concerning,” Buetti-Sgouros said. “They could potentially have no symptoms at all and then spread it to a grandparent who comes to visit who hasn’t seen them in a long time.”
Said Bookner, “Not that PMIS is not a concern, but it’s still a bigger concern that kids being all together is going to just increase the spread of disease in general. Kids being kids, they’re not able to be as careful as adults.”
In addition to the negative economic impact of quarantine, medically speaking the issue is that people are not out there building antibodies, which doesn’t help herd immunity. Once 70 percent of the population generates antibodies, Buetti-Sgouros said that will help protect the rest of the community, though there will still be those at-risk groups like the elderly, the immunocompromised and those with pre-existing conditions.
“I think it’s going to take a long time if we’re shut away in quarantine to naturally come up with that number of people with antibodies,” Buetti-Sgouros said. “It’s going to be very important when that vaccine comes out for people to start getting it providing it’s safe and effective. That’s my big thing. I really wish we could open up everything. But when we do, I think you’ll see another spike in cases because there’s going to be asymptomatic spreading to those who might be more susceptible and then everyone will freak out and they’ll close everything down.”
Bookner doesn’t think the current number of PMIS cases is enough to impact reopening the state in phases. “I think we should still base opening up society based on guidelines that show the number of cases of the [COVID-19] virus are decreasing, overall illness is decreasing and we can start to safely open up without there being a spread of the virus,” he said.
Avoiding a “false sense of apocalypse” every time there’s a report of a tragic ending due to PMIS is crucial.
“Parents should definitely not panic,” Bookner said. “It’s like all of us with coronavirus. The chances of any one of us getting coronavirus and dying is very small, but it’s certainly not zero. We need to stay informed, we need to stay safe and do all the things we’re asked to do, but we should not panic.”
The challenge is finding the right balance moving forward. “It’s very hard to come up with a public health position that will help get rid of this in the near future,” Buetti-Sgouros said. “This is going to take time until we have enough people antibody positive that can really protect those most susceptible in society.”
The good news is that awareness is on the rise.
“We’re all becoming Sherlock Holmes” Buetti-Sgouros said. “We’re all looking for the clues to try to crack the code of this virus and figure out how we can stop the spread.”