Child Health: The Indirect Specter of COVID-19

We can be grateful that the direct effects of infection with SARS-CoV-2 have been—for the most part—uncommon and usually mild in children. Perhaps more worrisome and significant, however, may be a plethora of unexpected indirect and potentially long-term effects of our responses to COVID-19. For example, recent reductions in reports of child abuse are thought to be due to decreased calls to child protective services by teachers as K-12 schools are shuttered.

Two recent reports, one from the U.S. and the other from abroad, should sound alarms to all primary care clinicians and child advocates. Assessments of diet, food availability and vaccination history are familiar parts of our usual well child visits. Moreover, food security and immunization are cornerstones of child health, and are now threatened by the pandemic.

Through the modeling of different scenarios with reductions in maternal and child health interventions and increases in food insecurity, due to the pandemic, Roberton and colleagues projected as many as 1,157,000 additional child deaths in low- and middle-income countries.[1] Food depravation, reduced antibiotic treatment for pneumonia and neonatal sepsis, and decreased use of oral rehydration solution for diarrhea contributed to a majority of the avoidable deaths.

Closer to home, a recent report in MMRW compared trends in routine vaccination across two periods (January 7—April 21, 2019 and January 6—April 19, 2020).[2] The authors used vaccine distribution data from the Vaccines for Children Program (VFC) as an indirect measure of vaccine administration as well as actual doses of measles-containing vaccine provided at Vaccine Safety Datalink (VSD) sites. Significant reductions in immunization occurred after the March 13, 2020 declaration of a national emergency, with the concomitant alterations in health care delivery and significantly reduced well child care visits. The cumulative net loss in VFC orders for all non-influenza vaccine doses over the study period was more than three million, including more than 400,000 doses of measles containing vaccine alone. A similar trend was noted from VSD sites, but with less of an impact for measles-containing vaccines in children ≤ 24 months of age. The authors state, “As social distancing requirements are relaxed, children who are not protected by vaccines will be more vulnerable to diseases such as measles.”

One other personal observation deals with ACEs, the Adverse Childhood Experiences.[3] When one considers the individual and cumulative effects of childhood emotional, physical and sexual abuse, food and household insecurity, witnessing parental abuse or the loss of a parent, having a family member suffer with depression, and exposure to alcohol or drug abuse in the home, the potential long-term toll of this ongoing pandemic is monumental. Compared to having no ACEs, children with exposure to 1-3 ACEs have—over their lifetime—a twofold increase risk for heart disease, an eightfold increase in alcoholism, a 10-fold increase in suicide risk and an 11-fold increase in likelihood to use intravenous drugs.

There is a tremendous need at this time to assure routine well child care. We need to employ all the tricks up our collective sleeves to conduct outreach, get patients back in our clinics, make home visits, conduct telemedicine and video visits, and fully utilize all of our clinical staff to assess immunization status and update vaccines, evaluate food insecurity, discover familial and household stresses, and assist in finding the needed community resources to get through the coming months of adversity.