Omicron in Kids: Humility in the Face of Uncertainty
‘Security is mostly a superstition. It does not exist in nature.’
At the time of writing, parents are facing a difficult choice.
Choice one, vaccinate, then have your child infected by Omicron with an immune system primed to mount a robust anti-viral response.
Choice two, don’t vaccinate and let your child get infected by Omicron without a primed immune response.
The SARS-CoV-2 pandemic is a rapidly evolving situation that has placed significant stress on our institutions. As a result, many difficult decisions have been made with incomplete knowledge.
The degree of uncertainty is particularly high when considering children, COVID-19, and vaccination.
For a start, COVID in children is woefully understudied. Because of this, we don’t understand the long-term consequences of SARS-CoV-2 infection in children and adolescents.
Second, Omicron is a new variant that is spreading rapidly. Unfortunately, we currently have no data regarding the long-term effects of Omicron infection in kids and teenagers.
Finally, we are using new vaccine technology that has only recently been approved for use in children and adolescents.
Given the high degree of uncertainty surrounding COVID and children, there is a non-trivial probability of one’s opinion being wrong.
Children Under the Age of Five
The focus of this article is children aged 5-16 because this age group is now eligible for SARS-CoV-2 vaccination. Unfortunately, children younger than 5 who catch SARS-CoV-2 are at a higher risk of severe COVID-19 and hospitalization than the 5-16 age group (1).
Symptoms in very young children include fever (47%), cough (40%), vomiting (24%), difficulty breathing (23%), diarrhea (20%), and convulsions (20%) (1). If you have a young child under five years old who shows any of these symptoms, please immediately seek professional medical advice.
Luckily, the most recent data suggests that Omicron causes a much milder illness than Delta in children under five (2). Specifically, Omicron infections had a 29% reduction in ED visits, 67% reduction in hospitalizations, 68% reduction in ICU admissions, and 71% reduction in mechanical ventilation compared to the Delta variant (2).
Most importantly, deaths from Omicron within the 0-5 age bracket are exceedingly rare (2).
Low Risk of Death from COVID-19 in Children Aged 5-16
The most important message from this article is this: The risk of death for children and adolescents from SARS-CoV-2 is extremely low.
Thankfully, most children within the 5-16-year-old age group experience asymptomatic or mild disease.
For example, a large study revealed that deaths from COVID-19 in children were approximately 0·17 per 100 000 population (3).
Furthermore, the risk of children and adolescents dying from SARS-CoV-2 has remained low during the current Omicron wave. As shown in Figure One, although children and adolescents are being infected by SARS-CoV-2 (at a much lower rate than adults), the death rate in children under 19 remains extremely low.
How low? In the USA, childhood (aged 0-18) deaths from COVID-19 make up 0.1% of the total COVID-19 deaths as of January 15, 2022.
Thus, the risk of children dying from COVID-19 is low (but not zero).
Children with co-morbidities have an elevated risk of severe disease and death from SARS-CoV-2 infection (4). For example, children with chronic pulmonary disease (including asthma), severe obesity, neurologic diseases, cardiovascular diseases, metabolic diseases, and immune suppression are at greater risk of severe COVID-19 (4).
Fortunately, however, for most children with co-morbidities, the risk of death remains low (4). Nevertheless, children with co-morbidities require an elevated level of care.
Low Risk of Serious Disease
In most cases, SARS-CoV-2 infections cause mild-to-moderate illness in children (5). For example, for children younger than 16 infected with SARS-CoV-2, it’s estimated that 15% are asymptomatic (15%), 40% have mild symptoms, and 40% experience moderate illness (6).
Further, children infected by SARS-CoV-2 rarely require hospital admission or intensive care (5). Nevertheless, it’s important to note that a low percentage of children and adolescents succumb to serious illness when infected with SARS-CoV-2 and require hospitalization (5).
For example, children experiencing moderate and severe cases of COVID-19 can progress to pneumonia (5). Pneumonia presents with multiple associated symptoms, i.e., fever, cough, muscle aches and pains, signs of respiratory distress, bluish skin, neurological signs and symptoms, trouble feeding, and signs of dehydration (5).
SARS-CoV-2 infected children can also develop acute respiratory distress syndrome (ARDS). ARDS occurs when fluid builds up in your child’s lungs, which reduces their blood oxygen levels. A small percentage of children who develop ARDS require ventilation (5).
Thus, children infected with SARS-CoV-2 can develop serious diseases requiring hospitalization, ICU, and ventilation.
Fortunately, however, children who progress to pneumonia or ARDS have a good prognosis, with most making a full recovery (5).
COVID-19-associated multi-system inflammatory syndrome in children (MIS-C)
MIS-C is a rare post-COVID- 19 complications in children, with an incidence of approximately 0.14% (5). MIS-C usually occurs 2-6 weeks after SARS-CoV-2 infection. Symptoms of MIS-C include a high fever, abdominal pain, vomiting, diarrhea, rash, conjunctivitis, and low blood pressure.
Untreated, MIS-C can be deadly. Fortunately, few cases of MIS-C require admission to an intensive care unit (ICU) (5). Further, and under appropriate medical care, the prognosis of children making a complete recovery is good (5). That said, MIS-C imposes an elevated risk of neurological damage to children and adolescents (13).
However, the latest data from the CDC suggests that Omicron infections may have a very low risk of progressing to MIS-C (Figure Two). If this trend holds true (and isn’t due to some data delay), it will be great news indeed.
Long COVID is a debilitating syndrome that occurs in adults after infection with SARS-CoV-2 (8).
Worryingly, long COVID appears to be a relatively common after-effect of COVID-19 that can occur after a mild SARS-CoV-2 infection (8). At present, over 1·2 million people living in the UK have self-reported long COVID (9).
Worse, there is emerging evidence that long-COVID also occurs in children and young adults (10, 11). For example, the prevalence of long-covid in children and adolescents hospitalized with SARS-CoV-2 may be as high as 4-5% (12). Consistent with this grim prediction, in the UK, long COVID was reported in around 77 000 children aged 2–16 years and 134 000 people aged 17–25 years (9).
Long-COVID symptoms in children include fatigue, difficulty in concentrating (brain fog), sleep disturbances, sensory problems, heart palpitations, and chest pains (13).
Thus, we know that children and adolescents are at risk of long-COVID. Unfortunately, the risk of Omicron causing long-COVID is unknown.
Severe complications of COVID-19 in the young include shock, brain disorders, heart injury or heart failure, clotting disorders, and acute kidney injury (5). Furthermore, complications involving organ dysfunction (e.g., brain, heart, kidney) pose a significant risk of death and increase the probability of long-term disability (5).
For example, approximately half of adults who had recovered from COVID-19 display heart abnormalities as measured by cardiovascular magnetic resonance (CMR) (14). Fortunately, I am happy to report that the current evidence suggests that children rarely display heart abnormalities after COVID-19 (15, 16). Whew!
|Neurological Symptoms||% of Hospitalized Cases|
|Loss of Smell||4.0|
However, adults face long-term neurological complications (10) and neurological diseases after COVID-19 (17, 18). Sadly, similar long-term neurological effects may occur in children (19). For example, out of 1334 children and adolescents hospitalized with COVID-19 in the UK, 51 presented with neurological or psychiatric disorders related to SARS-CoV-2 infection (7). In the US, forty percent of children hospitalized with acute SARS-CoV-2 infection (i.e., COVID-19) presented with at least one neurologic sign or symptom (Table One) (20).
Thus, children and adolescents hospitalized from COVID-19 are at risk of neurological damage (7, 20). Further, the risk of neurological damage faced by non-hospitalized children and adolescents remains unknown.
Unfortunately, because the Omicron variant hasn’t been around long enough, there is no data on how Omicron infection impacts long-term neurological health.
Vaccines and Long-COVID
Do vaccines protect your children against long-COVID? Hopefully, yes.
Data obtained from 1·2 million users of a COVID symptom tracker app in the UK showed that the risk of developing long COVID was reduced by around 50% in those who were double vaccinated (9).
Moreover, a very recent publication gave booster (mRNA) vaccines to patients suffering long-COVID (21). Strikingly, all long-COVID patients who received a booster vaccine showed a marked reduction in inflammation and a simultaneous boost of antibodies against SARS-CoV-2 (21).
How does all this relate to the current Omicron strain?
Well, vaccination likely reduces the risk of Omicron leaving the upper respiratory tract and infecting organs in your child’s body by providing a robust cell-mediated immunity against the Omicron strain (22, 23). In addition, vaccination may reduce the risk of runaway inflammation that is the hallmark of severe COVID-19 and likely a contributing factor to long-COVID (21).
Thus, studies in adults show that vaccination protects against organ damage, chronic infection, and runaway inflammation. Hopefully, vaccines will also reduce the long-term risks of SARS-CoV-2 infection in children and adolescents. However, long-term studies are required to confirm whether vaccination protects children against long-COVID and long-term disability after Omicron infection.
As we’ve discussed, the current evidence suggests that the Omicron variant causes a less-severe disease in adults than earlier SARS-CoV-2, especially when compared to the Delta variant. Does Omicron also cause less severe disease in children and adolescents?
Fortunately, the answer appears to be yes. Omicron causes significantly less severe disease, hospitalization, fewer ICU admissions, and less mechanical ventilation in children and adolescents than the Delta variant (2, 24).
Most promising of all, the latest data from the CDC suggests that children infected with Omicron may have a low risk of progressing to MIS-C compared to earlier variants (Figure Two).
Thus, early evidence supports the hypothesis that Omicron poses a reduced risk of severe disease, progression to MIS-C, and death for children and adolescents, which is excellent news. Unfortunately, however, no data exist regarding the long-term health consequences of the Omicron strain in children and adolescents.
Vaccine Safety and Efficacy in the Real World
Independent monitoring of vaccine efficacy in large populations has consistently shown that mRNA vaccines provide strong protection against severe disease and death from COVID-19. Because current vaccines still provide robust cell-mediated immunity against Omicron (26), they have continued to protect the vaccinated from death and severe disease during the Omicron wave (Figure Three).
How well do vaccines protect young people against SARS-CoV-2? Well, vaccine effectiveness against symptomatic SARS-CoV-2 infection in over 400,000 South Korean adolescents was 99.1%, confirming the high efficacy of the mRNA vaccine within a sizeable adolescent population (25).
In conclusion, mRNA vaccines protect against severe disease and death from COVID-19, including Omicron.
While promising, the original vaccine clinical trials performed in children and adolescents did not include sufficiently large numbers of kids to detect rare adverse events. Therefore, more extensive monitoring was required to reveal rare side effects such as heart inflammation.
For example, among 444,313 South Korean adolescents who received the first dose of vaccine, the rate for myocarditis was 18 per million among first-dose recipients and 43 per million in second-dose recipients (25).
In Denmark, from a sample of 133,477 vaccinated adolescent males and 127,857 vaccinated adolescent females 12–17 years of age, myocarditis occurred in 97 males and 16 females per million (27).
Please note, however, that the incidence of heart inflammation in Danish adolescents infected with SARS-CoV-2 was significantly higher than after vaccination in both males and females (27).
Moreover, independent research confirmed that adolescents infected with SARS-CoV-2 may have a higher rate of heart inflammation than their vaccinated peers (28). Myocarditis from COVID-19 occurred at a rate as high as 450 per million in young males, roughly six times more than those who received the vaccine (28).
Thus, while mRNA vaccination increases heart inflammation risk, so does SARS-CoV-2 infection. Unfortunately, however, the risk of heart inflammation with the new, milder Omicron variant is unknown.
Resolution of vaccine-induced heart inflammation
Fortunately, most cases of vaccine-induced heart inflammation have a mild clinical course with rapid resolution of symptoms (29-32). However, heart inflammation does require hospitalization (31, 32). Therefore, you should take the risk of vaccine-induced heart inflammation seriously.
Reducing the Risk of Vaccine-Induced Myocarditis after Vaccination or Omicron Infection
Heart inflammation can occur either after vaccination or during and after SARS-CoV-2 infection. Therefore, all parents should be on the lookout for signs and symptoms of heart inflammation in their kids. If you suspect your child has heart inflammation, get them to the Emergency Department as soon as possible.
- Chest Pain
- Breathing Difficulties
- Rapid breathing
- Rapid or irregular heart rhythms (arrhythmias)
Pericarditis is swelling and irritation of the tissue surrounding the heart. Symptoms include
- Sharp chest pain.
- Pericarditis pain usually occurs behind the breastbone or on the left side of the chest. The pain may:
- Spread to the left shoulder and neck
- Get worse when coughing, lying down, or taking a deep breath
- Get better when sitting up or leaning forward
Other signs and symptoms of pericarditis may include:
- Fatigue or a general feeling of weakness or being sick
- Leg swelling
- Low-grade fever
- Pounding or racing heartbeat (heart palpitations)
- Shortness of breath when lying down
- Swelling of the belly (abdomen)
After vaccination, the most common symptom in patients with heart inflammation is pain or pressure in the chest and sometimes shortness of breath (33).
Myocarditis usually presents 3 days, and pericarditis 7-8 days after vaccination (33). Thus, if you see symptoms of heart inflammation in your child within a week or two after vaccination or during or after any viral infection (i.e., not just Omicron), please seek medical assistance immediately.
The good news is that children and adolescents are at low risk for serious disease from COVID-19. Furthermore, early data suggests that the new Omicron variant may pose significantly less risk to children than earlier SARS-CoV-2 variants with respect to serious illness and death.
More good news is that mRNA vaccination is a low-risk intervention that protects against severe COVID-19 disease, long-term disability, and death. However, large-scale monitoring has revealed that mRNA vaccines have rare side effects, most notably heart inflammation in young males. Fortunately, post-vaccine heart inflammation is extremely rare and is a mild and transient condition under medical supervision.
The bad news is that children and adolescents infected by SARS-CoV-2 are at risk of long-COVID, and neurological damage. Unfortunately, the long-term risks of COVID-19 for the young are poorly understood. Furthermore, the long-term health risks of Omicron infection for children and adolescents are currently unknown.
The unfortunate reality is that parents must decide whether to vaccinate their children during a time of rapid change and uncertainty.
References and Further Reading
1. J. Cloete et al., Rapid rise in paediatric COVID-19 hospitalisations during the early stages of the Omicron wave, Tshwane District, South Africa. medRxiv, (2021).
2. L. Wang et al., COVID infection severity in children under 5 years old before and after Omicron emergence in the US. medRxiv, (2022).
3. S. S. Bhopal, J. Bagaria, B. Olabi, R. Bhopal, Children and young people remain at low risk of COVID-19 mortality. The Lancet Child & Adolescent Health 5, e12-e13 (2021).
4. B. K. Tsankov et al., Severe COVID-19 Infection and Pediatric Comorbidities: A Systematic Review and Meta-Analysis. Int J Infect Dis 103, 246-256 (2021).
5. M. Borrelli, A. Corcione, F. Castellano, F. Fiori Nastro, F. Santamaria, Coronavirus Disease 2019 in Children. Frontiers in Pediatrics 9, 481 (2021).
6. M. M. Martins, A. Prata-Barbosa, A. J. L. A. da Cunha, Update on SARS-CoV-2 infection in children. Paediatrics and International Child Health 41, 56-64 (2021).
7. S. T. J. Ray et al., Neurological manifestations of SARS-CoV-2 infection in hospitalised children and adolescents in the UK: a prospective national cohort study. Lancet Child Adolesc Health 5, 631-641 (2021).
8. H. Ledford, Do vaccines protect against long COVID? What the data say. Nature 599, 546-548 (2021).
9. P. Venkatesan, Do vaccines protect from long COVID? Lancet Respir Med, (2022).
10. P. Zimmermann, L. F. Pittet, N. Curtis, How Common is Long COVID in Children and Adolescents? Pediatr Infect Dis J 40, e482-e487 (2021).
11. T. Radtke, A. Ulyte, M. A. Puhan, S. Kriemler, Long-term Symptoms After SARS-CoV-2 Infection in Children and Adolescents. Jama 326, 869-871 (2021).
12. F. Miller et al., Prevalence of persistent symptoms in children during the COVID-19 pandemic: evidence from a household cohort study in England and Wales. medRxiv, (2021).
13. M. Borel, L. Xie, A. Mihalcea, J. Kahn, S. E. Messiah, Long Term Physical, Mental and Social Health Effects of COVID-19 in the Pediatric Population: A Scoping Review. medRxiv, 2021.2009.2017.21263743 (2021).
14. J. Y. Kim, K. Han, Y. J. Suh, Prevalence of abnormal cardiovascular magnetic resonance findings in recovered patients from COVID-19: a systematic review and meta-analysis. Journal of Cardiovascular Magnetic Resonance 23, 1-22 (2021).
15. G. Webster et al., Cardiovascular magnetic resonance imaging in children after recovery from symptomatic COVID-19 or MIS-C: a prospective study. Journal of Cardiovascular Magnetic Resonance 23, 1-7 (2021).
16. F. Seidel et al., Cardiovascular magnetic resonance findings in non‐hospitalized paediatric patients after recovery from COVID‐19. ESC Heart Failure, (2021).
17. S. Misra et al., Frequency of Neurologic Manifestations in COVID-19: A Systematic Review and Meta-analysis. Neurology 97, e2269-e2281 (2021).
18. S. Bhola et al., Neurological toll of COVID-19. Neurol Sci, 1-16 (2022).
19. S. Khan et al., The COVID-19 infection in children and its association with the immune system, prenatal stress, and neurological complications. Int J Biol Sci 18, 707-716 (2022).
20. E. L. Fink, C. L. Robertson, M. S. Wainwright, J. D. Roa, M. E. Schober, Prevalence and Risk Factors of Neurologic Manifestations in Hospitalized Children Diagnosed with Acute SARS-CoV-2 or MIS-C. Pediatric Neurology.
21. A. Hoque, M. M. Rahman, H. Imam, N. Nahar, F. U. Hasan Chowdhury, Third dose vaccine With BNT162b2 and its response on Long COVID after Breakthrough infections. medRxiv, 2021.2011.2008.21266037 (2021).
22. S. F. Ahmed, A. A. Quadeer, M. R. McKay, SARS-CoV-2 T cell responses are expected to remain robust against Omicron. bioRxiv, 2021.2012.2012.472315 (2021).
23. L. De Marco et al., Preserved T cell reactivity to the SARS-CoV-2 Omicron variant indicates continued protection in vaccinated individuals. bioRxiv, 2021.2012.2030.474453 (2021).
24. L. Wang et al., Comparison of outcomes from COVID infection in pediatric and adult patients before and after the emergence of Omicron. medRxiv, (2022).
25. Y. June Choe et al., Safety and effectiveness of BNT162b2 mRNA Covid-19 vaccine in adolescents. Vaccine 40, 691-694 (2021).
26. A. Tarke et al., SARS-CoV-2 vaccination induces immunological T cell memory able to cross-recognize variants from Alpha to Omicron. Cell, (2022).
27. U. Nygaard et al., Population-based Incidence of Myopericarditis After COVID-19 Vaccination in Danish Adolescents. Pediatr Infect Dis J 41, e25-e28 (2022).
28. M. E. Singer, I. B. Taub, D. C. Kaelber, Risk of myocarditis from COVID-19 infection in people under age 20: a population-based analysis. medRxiv, (2021).
29. D. Mevorach et al., Myocarditis after BNT162b2 mRNA Vaccine against Covid-19 in Israel. N Engl J Med 385, 2140-2149 (2021).
30. A. Matta et al., Clinical Presentation and Outcomes of Myocarditis Post mRNA Vaccination: A Meta-Analysis and Systematic Review. Cureus 13, e19240 (2021).
31. J. Park, D. R. Brekke, A. Bratincsak, Self-limited myocarditis presenting with chest pain and ST segment elevation in adolescents after vaccination with the BNT162b2 mRNA vaccine. Cardiol Young 32, 146-149 (2022).
32. D. T. Truong et al., Clinically Suspected Myocarditis Temporally Related to COVID-19 Vaccination in Adolescents and Young Adults. Circulation, (2021).
33. J. Pillay et al., Myocarditis and pericarditis following COVID-19 vaccination: Rapid systematic review of incidence, risk factors, and clinical course. medRxiv, (2021).
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