In the Ongoing Conflict Between Ideology and Immunity, Which Side Will Protect the Children From Post-Acute Sequelae of COVID-19?

The United States is currently riven by deep and bitter ideological and political fissures that threaten to diminish the health and well-being of future generations of Americans because of our inability to embrace public health measures that are necessary to contain the spread of the coronavirus. This Editor’s Page we will not delve into how or why the fissures developed in America, nor will we point accusatory fingers at one political side or the other. Rather we seek to highlight a growing concern that we are sowing the seeds of our future demise as a nation by not paying sufficient attention to how the current pandemic may affect the most vulnerable members of our society: our children.

According to the American Academy of Pediatrics reports, more than 4.5 million children have tested positive for COVID-19 since the beginning of the pandemic, making up about 15% of all cases in the United States (1). With the COVID-19 delta variant, not only is the rate of infection rising in children but also the severity of infection and complications. As we have learned in time with adults, the health consequences of COVID-19 can outlast the acute infectious period and cause persistent and even debilitating symptoms in what has been termed long COVID, long-haul COVID, and more recently the formalized term post-acute sequelae of COVID-19 (PASC).

First recognized in adults, PASC is beginning to emerge as a new area of concern in children, and its clinical contours in children are still being defined (2). In one study of PASC in children in Italy, that has the longest described follow-up to date, 129 children ≤18 years of age with confirmed COVID-19 infection were evaluated for persistent symptoms. With an average assessment time of 162 days following COVID-19 infection, only 41.8% were completely recovered. The most common symptoms in these children included respiratory issues such as pain and chest tightness, nasal congestion, fatigue, muscle and joint pain, and concentration difficulties. Interestingly, these symptoms were in children who had both asymptomatic and symptomatic acute COVID-19 infection, debunking the presumption that the mild illness COVID-19 often causes in children is inconsequential and not worrisome (3). In a recent larger study from the United Kingdom, 1,734 children aged 5-17 years with confirmed COVID-19 infection were assessed. In contrast to the Italian study, the average duration of illness was 6 days, with only 4.4% of children having symptoms beyond 28 days from infection and only 1.8% having symptoms beyond 56 days. The most common persistent symptoms these children in were anosmia, headache, and fatigue (4).

Although the data for PASC in children are limited at the time of this writing, the description of symptoms as well as variation of rates and duration of symptoms is similar to PASC in adults. A key difference, however, is that the effects of PASC in adults are more readily visible, with more tangible consequences than in children. In adults, the consequences of PASC are seen as the patient loses his or her job, becomes unemployed, and/or must move in with family because they cannot care for themselves. It bears emphasis that the significance of PASC in children has not yet been established. More concerning is that long-term consequences of PASC may be more difficult to recognize in children than in adults. For example, the hypoxic respiratory failure that occurs with acute COVID-19 infection in children could lead to neurodevelopment and/or educational delays. The chronic chest pain and dyspnea associated with PASC in children could lead to decreased physical activity and increased childhood obesity. Although the vertical transmission of SARS-CoV-2 from mother to fetus is rare, maternal infection can compromise maternal and placental health that could lead to issues with organogenesis (specifically fetal brain development due to maternal stress levels/exposure to excess glucocorticoids), preeclampsia and preterm birth, and intrauterine growth restriction (5).

Ideology Versus Immunity

Epidemiologic studies of the COVID-19 pandemic have shown convincingly that when it comes to the outcome of the conflict between ideology and immunity, the delta variant of SARS-CoV-2 wins in nonvaccinated people. Understanding that young children are not eligible for vaccination against COVID-19, and recognizing that COVID-19 may lead to long term post-acute sequelae that may deny future generations the ability to pursue lives that are unencumbered by chronic illnesses that were acquired during childhood, shouldn’t we as responsible adults do everything we can to protect the well-being and safety of the children by raising them in the safest environments possible? Given that the sustainability and vibrancy of any society is inextricably intertwined with the heath of its people, it is crucial that we put our personal and political differences aside, and affirm the value of our shared humanity, by ensuring that our children are raised in safe environments, surrounded by adults who are COVID free, even if this means we have to sacrifice personal freedoms in the short term to do so. As always, we welcome your thoughts on this editorial, either through social media (#JACC:BTS) or by email (jaccbts@acc.org).