Children are being sidelined by covid-19BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2061 (Published 27 May 2020) Cite this as: BMJ 2020;369:m2061
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Children have certainly been side-lined(1) and I believe we have a brewing problem which will be the domino effect of this pandemic.
Primary healthcare services were not spared in the rerouting of care(1). With redeployment of staff to cover acute services and observance of social distancing rules the landscape of the community support normally available to families changed. Those health visitors that were still working in their roles could no longer ‘visit’ homes resorting to video calls to families with newborn babies where possible. The first few weeks of a child’s life are definitely some of their busiest with multiple contact from community midwife and health visiting teams for routine checks(1) and feeding support. Babies that have been born during this time and their parents have had to walk a tightrope with no safety net and as to be expected they are some that have got hurt in the process. Significant weight loss well outside of the expected range in the first few days of life has seen babies being admitted to hospitals for feeding support - cases where closer monitoring in the home would have potentially kept families together.
Other parents in their reluctance to come to hospital for fear of their newborn contracting covid 19 and some through sheer resilience are holding on, fighting battles with feeding problems at home only presenting much further along the line with babies that have still not regained birth weight and at the end of their tether which does nothing for their journey to re-establishing a happy feeding environment.
What I have begun to see in my daily practice I believe is just the tip of what is to come. After the dust settles and we are back to what may be our new normal way of working I wonder how many cases that highlight missed opportunities will present to us. A coeliac disease diagnosis that could have been made if the child had been examined, that referral for support in developmental delay, that cow’s milk protein allergy in a baby that could have been resolved with appropriate intervention before feeds became a constant source of pain for the baby; the list is going to be long.
As clinicians we have a role to play in reducing these cases. As always and even more importantly now, every patient contact should count as if it is the only one to be had. Where we cannot touch may we look closely and identify patterns, where we can neither touch nor see and the telephone consultation is our only friend may we prepare and build a picture in our mind’s eye and may we not just hear our patients but instead listen with all our senses. Whilst we are unable to demonstrate nonverbal cues during telephone consultations; let us maximise on the other components of active listening by reflecting the message through paraphrasing and asking questions that promote clarification(2).
Through years of medical training and clinical practice we have developed clinical gestalt(3) - an untaught skill which all clinicians have, let us now rely on our gut intuition for when things are just not right.
Equally important is identifying risk in those we have not met through those that are with us, as we do our best to manage the illnesses that our patients present with let us remember to pause and check in on the family that has been left at home.
I cherish the hope that the contagion effect of this pandemic will not be worse than what we are already experiencing in the devastating loss of our patients and loved ones. Time will tell.
1. Children are being sidelined by covid-19. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2061
2. Cook, C., 2009. Is Clinical Gestalt Good Enough?. Journal of Manual & Manipulative Therapy, 17(1), pp.6-7.
3. Weger, H., Castle Bell, G., Minei, E. and Robinson, M., 2014. The Relative Effectiveness of Active Listening in Initial Interactions. International Journal of Listening, 28(1), pp.13-31.
Competing interests: No competing interests
COVID-19 Pandemic and the peculiar affliction of children: Amplification of a social fault cleavage that must be fixed
The World has in its ‘Complex Architecture’ several worrisome ‘Social Fault Lines’ that are ‘Generously Signposted’ with ‘Unacceptable Inequalities and Inequities’! It is an urgent imperative for the World to eclipse ALL ‘Forms of Social Disparities’!! While the World grapples with the ‘Difficult Challenges’ to eliminate these ‘Social Fault Cleavages’, the equally challenging ‘Unprecedented Ravaging 21st Century Devastating Pandemic’ has compounded the Impact of the ‘Social Disparities’. With every ‘Human Crisis’, there is amplification of the ‘Social Fault Cleavages’ with the consequences that ‘Children and the Young’ and those with ‘Known Vulnerabilities’ are the most affected/ afflicted 1,2]! Some ‘Learnt Lessons from Past Events’ are quite ‘Instructive/ Informative’: The ‘Titanic Disaster Survivors’ disposed a ‘Correlation’ between ‘Social Class’ and the ‘Risk of Drowning’  and the ‘Upper Social Class’ largely survived the ‘Bubonic Plague’  just as ‘Cases-in-Point’!! The ‘Huge Unprecedented Devastations’ wreaked by the ‘COVID-19 Pandemic’ have been widely exposed in previous ‘Communications’ [5-7]. The current ‘Communication’, therefore, focuses on the amplification of the ‘Social Fault Cleavage’ by the ‘COVID-19 Pandemic’ and signposted by the ‘Palpable Inequalities and Inequities’ against ‘Children and the Young’ [1,2]!
The United Nations warns that ‘Child Rights and Safety’ risk being compromised by the ‘COVID-19 Pandemic’ and it has also been emphasized that children MUST not be left behind in the aftermath of the ‘Pandemic’ [8,9]! Children do not widely enjoy the benefit of the best when the ‘Determinants of Health’ are disposed: Living Conditions, Employment, Family Income, Access to Health Services, Education etc ! The ‘Forced Focus’ on, and the ‘Diverted Attention and Resources’ to, the ‘COVID-19 Pandemic’ necessarily further amplifies ‘Children’s Deprivations’ in relation to the ‘Determinants of Health’ with the resultant worsening of their ‘Health Status’! Children thus have much reduced possibilities for ‘Enhanced Health Status’ in the ‘COVID-19 Pandemic Era’ re: Exposure to Poverty, Compromised Environment, Nutritional Inadequacy, Unacceptable Housing, Polluted Air, Poor Water and Sanitation Situations etc! With the ‘COVID-19 Pandemic’, and in the face of ‘Compromised Health Status’, children are further exposed to ‘Aggravated Deprivations’: Lack of Critical Care Services, Compromised Follow-up Care for Pre-Existing Morbidities, Inadequate Promotive and Preventive Interventions for Optimal Development, Questionable Immunization Services, Inefficient Child Protection Services etc!!
The ‘COVID-19 Pandemic Interventions’ that are proven to be Efficient and Effective are the ‘Non-Pharmaceutical Interventions (NPIs)’! These include, among several others, ‘Lockdowns’!! The ‘Myriad of Possibilities’ is legion: Country Lockdown, Economy Shutdown, Travel Shutdown, School Shutdown, Sports Championships Shutdown, Religious Worships Shutdown, Conferences Shutdown etc. Effective as it is, the ‘Pandemic-induced Lockdown’ has its ‘Huge Burden and Difficulties’ ! For this ‘Communication’, the peculiar ‘Implications and Difficulties’ of ‘Lockdown’ on children are amplified as ‘Tantalizing Teasers’: Increased Neglect and Abuse, More Domestic Violence, Disruptions in Education and Social Life, Overcrowded Housing, Questionable Water, Sanitation and Hygiene Conditions!! These aggravate the ‘Consequences and Pandemic Impact’ on ‘Children and the Young’!!!
Another perspective to the ‘Implications and Impact’ of the ‘COVID-19 Pandemic’ on ‘Children and the Young’ is the ‘Rapidly Dynamically Transmuting Information and Research Data’ concerning ‘Whether or not Children are affected’ and, indeed, ‘How Children are affected’! Concerning ‘Children and the Young’, the ‘COVID-19 Pandemic Literature is in a Flux’ and this confounds the peculiar ‘Difficulties and Implications’ for this ‘Disadvantaged Group’ in defined Populations!! Increasingly, new ‘Clinical Conditions’ or ‘Clinical Syndromes’ are being reported to dispose the ‘Peculiar Afflictions’ of ‘Children and the Young’:
1. MicroCLOTS: ‘Microvascular COVID-19 Lung vessel Obstructive Thromboinflammatory Syndrome’ which is a ‘Coagulation Disorder’ with ‘Widespread Microclots’ in the Lungs and other ‘Organs/ Tissues’ [11,12]!
2. MIS-C (PMIS, PIMS): ‘Multi-System Inflammatory Syndrome in Children’ (Also ‘Paediatric Multi-System Inflammatory Syndrome (PMIS)’ and ‘Paediatric Inflammatory Multi-System Syndrome (PIMS)’) in which a ‘Systemic Vasculitis’ like ‘Kawasaki Syndrome’ affects multiple ‘Organs/ Tissues’ [13,14]!
3. Cytokine Storm Syndrome (CSS): ‘Hyper-Immune Reaction’ in which ‘Cytokines’ (Especially Il-6) are excessively produced and released in response to the ‘COVID-19’ !
4. Chronic Fatigue Syndrome: Children suffer prolonged affliction and develop this ‘Syndrome’ as a consequence!
These ‘Unusual Disease Manifestations’ in ‘Children and the Young’ create ‘Increased Difficulties’ with ‘Diagnosis’, ‘Treatment’ and ‘Stress and Burden’ in a peculiar manner! The ‘Therapeutics’ involves the search for ‘Drugs that Work’: Antivirals, Anticoagulants, Anti-Cytokines etc!!
The UNICEF  has identified the ‘Thrusts of Interventions’ to address the ‘COVID-19 Pandemic Peculiarities in Children and Young’: ‘Keep Children Healthy, Safe and Learning’! This undergirds the ‘UNICEF 6-Pillar Agenda for Action’ with the following:
1. Keep Children Healthy and Safe
2. Reach Children with Water, Sanitation and Hygiene
3. Keep Children Learning
4. Support Families to cover the Needs and Care for their Children
5. Protect Children from Violence, Exploitation and Abuse
6. Protect Refugees and Migrant Children and those affected by Conflict
These ‘Six Pillars’ address the identified ‘Unacceptable Social Disparities against Children’! The ‘COVID-19 Pandemic’ has caused ‘School Disruption’ in over 91% of a ‘Generation of Children’ with the POTENTIALITY for ‘Our Compromised Future’ !! Over 40% of the World’s Population is without adequate Water, Sanitation and Hand-washing Facilities; this is worse at 75% in the Least Developed Countries !! The ‘Interventional Panacea’ is to address the following as they affect Children: Education, Nutrition, Child Protection, Water, Sanitation, Housing etc! Children MUST not be allowed to become the ‘Hidden Victims’ of the ‘COVID-19 Pandemic’1!!
To achieve a ‘Comprehensive Approach’ to the ‘Global Fight’ against the ‘COVID-19 Pandemic’, the World MUST explore and compositely address the ‘Identified Components’ of the ‘COVID-19 Pandemic Tragic Octad’ !! The ‘Social Fault Line’ signposted by ‘Inequalities and Inequities against Children’ MUST be identified, Addressed and Fixed for ‘Our Common Humanity and Tomorrow’ as the peculiarities of ‘COVID-19 Pandemic Afflicted Children’ are in focus!! With ‘National Unity’, ‘Global Solidarity’ and ‘Quarantining Politics’, as recommended by the WHO, the World MUST avoid ‘Interventional Precocity in Easing Lockdowns’ to assure ‘Sustainable Victory’ in the ‘COVID-19 Pandemic Fight’ !!
This ‘Communication’ highlights the enlarging ‘COVID-19 Pandemic Peculiarities of Afflicted Children Conversation’! The Children MUST not become the ‘Hidden Victims’ and those ‘Left behind in its Aftermath’!! There MUST be ‘Global Concerted Efforts’ to eclipse the ‘Unacceptable Persisting Social Fault Cleavages’ signposted by ‘Inequalities and Inequities against Children’!!
1. Fore H. Don’t let children be the hidden victims of COVID-19 pandemic. https://www.unicef.org/press-releases/dont-let-children-be-the-hidden-vi... of 9th April 2020
2. Sinha I, Bennett D, Taylor-Robinson DC. Children are being sidelined by Covid-19. BMJ 2020; 369:m2061
3. Hall W. Social class and survival on the S.S.Titanic. Soc Sci Med 1986; 22:687-90.
4. Cito, longe, tarde: fly quickly, go far, return slowly. The Repository, Royal Society. https://blogs.royalsociety.org/history-of-science/2015/03/09/great-plague/
5. Godlee F. COVID-19: Weathering the storm. BMJ 2020; 368:m1199 of 26th March 2020
6. Eregie C.O. COVID-19 Pandemic: Still on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-13 of 2nd April 2020
7. Eregie C.O. COVID-19 Pandemic: Further perspectives on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-16 of 5th April 2020
8. United Nations. Policy brief: the impact of covid-19 on children. https://www.un.org/sites/un2.un.org/files/policy_brief_on_covid_impact_o...
9. Whitehead M, Barr B, Taylor-Robinson D. Covid-19: we are not ‘all in it together’-less privileged in society are suffering the brunt of the damage. BMJ Opinion, 22 May 2020.https://blogs.bmj.com/bmj/2020/05/22/covid-19-we-are-not-all-in-it-toget...
10. Ioannidis JPA. Coronavirus disease 2019: The harms of exaggerated information and non-evidence-based measures. Eur J Clin Invest 2020; 50:e13222
11. Rettner R. Mysterious blood clots in COVID-19 patients have doctors alarmed. https://www.livescience.com/amp/coronavirus-blood-clots.html of 23rd April 2020
12. Willyard C. Coronavirus blood-clot mystery intensifies. https://www.nature.com/articles/d41586-020-01403-8 of 13th May 2020
13. Smith M. What Parents should know about Multi-System Inflammatory Syndrome in Children (MIS-C). https://www.chla.org/blog/health-and-safety-tips/what-parents-should-kno...
14. American Academy of Pediatrics. COVID-19 and Multi-System Inflammatory Syndrome in Children. https://www.healthychildren.org/English/health-issues/conditions/COVID-1... inflammatory condition.aspx of 25th June 2020
15. Levy HR, Suarez CI. COVID-19 and Cytokine Storm Syndrome. https://www.mlo-online.com/continuing-education/article/21138224/covid19... of 20th May 2020
16. Eregie CO. COVID-19 pandemic tragic octad: The evolving conceptual qualitative interventional equation to fight the pandemic. https://www.bmj.com/content/369/bmj.m2303/rr-9 of 24th June 2020
17. Eregie CO. COVID-19 Pandemic Interventions: Lockdown is not lockout; avoid interventional precocity with easing lockdowns. https://www.bmj.com/content/369/bmj.m2202/rr-4 of 14th June 2020
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria.
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.
Competing interests: No competing interests
During the period from the start of lockdown in England I have conducted General Paediatric telephone clinics, with on average eight consultations per session.
These consultations have included school aged children with chronic but medically inexplicable symptoms including: tiredness, headache, abdominal pain, dizziness, chronic fatigue and musculoskeletal pain.
In each case the parent has reported significant or complete resolution of symptoms, and this without the need for any medical or other therapeutic input. Some patients have improved to the degree that the parent has requested that the child be discharged from follow-up, in some cases after years of chronic symptoms. The clinical improvement increased with the duration of the lockdown, and not one patient had deteriorated in any way.
The only explanation I can conceive is that for these children their symptoms were a reflection of stress, anxiety or fear in some way related to school attendance.
Though there is no doubt that prolonged absence from school will have significant negative impact on the wellbeing of some children, and inevitably affect their educational achievements there are clearly other children for whom going to school is a traumatic experience.
Competing interests: No competing interests
I agree that the full impact of the COVID-19 lockdown on children and young people will continue to unfurl over the months and years ahead. As paediatricians we constantly battle to have the voices of children heard in hard pressed hospital trusts and other environments. But out of the fire our services must rise like phoenixes as we have the opportunity to redesign systems available to better enrich and support children.
One commonly recognised 'benefit' of the pandemic has been the dramatically reduced number of admissions to children's wards. This is not unique to the UK and was previously noted in both China and Italy primarily reassuring us that COVID-19 as an acute infection in children is dramatically different from adults. [1,2] However, the reduction in hospital attendances has not just been the lack of COVID infections but also a reduction on other expected acute presentations. In our paediatric respiratory service, we have seen hospital attendances of children with acute asthma/wheeze fall, almost overnight, from 3-5 children per day to 1-2 children per week since the lockdown. Overall attendance with asthma/ wheeze are approximately 95% lower than average for this time of year. Initially we feared that this represented families being too scared to attend hospitals but over eight weeks the situation hasn't changed, our asthma nurses are not overwhelmed with calls from worried parents of unwell children and our telephone outpatient reviews find most children in reportedly rude health.
So why has this change occurred? Sub-optimal adherence to prescribed controller therapy is a common factor in poor asthma control. It is possible that patients have become more assiduous in their adherence to treatment regimens driven by fear and public service broadcasts. This is difficult to assess objectively. Poor air quality is a recognised trigger for acute respiratory disease. The lockdown has produced substantial reductions in use of motor vehicles and air travel which should have resulted in improvement in air quality. Surprisingly air quality indices, including average daily PM10 and Nitrogen dioxide, measured in the locality of our hospital do not seem to show significant changes which could account for the reduction.  Other potential risk factors for asthma as highlighted in the editorial including 'toxic stress', 'poor quality and overcrowded housing' and reduced organised exercise seem to have manifested into acute attacks. 
The most significant change for the majority of children has been the closure of schools and distancing from their friends. For those who have been attending school during the lockdown, they are in smaller, socially distanced classes. Historically, hospital attendances with acute asthma decrease during school vacations but not to the same extent as seen in March 2020, presumably because in ‘normal’ times children continue to socialise outside their immediate family. It would therefore seem plausible that the transmission of other respiratory viruses has been halted by the unique measures put in place for the lockdown.
Asthma morbidity and mortality of children in the UK has been highlighted as a problem in recent years in comparison to our European neighbours. As we start to rebuild our society from the pandemic, we should learn from these unusual circumstances to see if other institutional factors can be improved to reduce non-COVID morbidity. Whilst the importance and benefits of school and education are undeniable, we should perhaps reflect on the environments that we put our children into and the impact that this may have on their health and in particular asthma. Whether it be the size and state of the school buildings, overcrowded classrooms with 30 children or the expectations of hand hygiene, all of which may impact on the spread of viruses. Looking forwards, it will be interesting to see how rapidly acute asthma presentations recur as schools re-open, particularly during the next winter viral season.
Children will be affected by COVID-19 for much of their lives educationally, financially and emotionally. As paediatricians we need to ensure that they benefit from any lessons learned through this unique time. Maybe one opportunity for our education policy makers is to review potential harms caused by current education system.
1. Clinical characteristics of COVID-19 in children compared with adults in Shandong Province, China. Du, W. Yu, J. Wang, H. et al. Infection 2020 https;//doi.org/10.1007/s15010-020-01427-2
2. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lazzerini, M. Barbi, E. Apicella, A. et al. Lancet Child Adolesc Health 2020; https://doi.org/10/1016/S2352-4642(20)30108-5
4. Children are being sidelined by covid-19. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2061
Competing interests: No competing interests
No doubt “Children are being sidelined by covid-19”. Others are even less fortunate.
When 40 global leaders pledged to raise £ 6.5 billion to fund development of a vaccine, and research into coronavirus, (1) that was less than half the £14 billion that the UK received for arms export sales in 2018 (2).
Far from being merely sidelined, children beyond the UK, are being mutilated, starved and killed in huge numbers when repressive regimes use imported weapon systems, as the Saudi Arabian-led forces have been doing in Yemen in recent years. (3). Those weapon systems are sold by ‘developed’ countries.
The fact that northern nations have been destroying the lives and cultures of people in more southerly countries, for centuries, should be common knowledge. (4,5,6 )
Nowadays we make money from selling the wherewithal for people to kill each other, while our national leaders proclaim their generous intentions to improve global health, when threatened by a virus.
Little wonder that Gandhi, when asked what he thought of western civilisation, replied, “It would be a good idea".
4 William Polk, Crusade and Jihad. Yale 2018
5 Toby Green, A Fistfull of Shells. Allen lane, 2019
6 William Dalrymple, The Anarchy. Bloomsbury, 2019.
Competing interests: No competing interests