Some people on social media and in conversations can often be heard to say that they can tell which variant they or someone else was infected with by the symptoms that dominated their illness. I have been skeptical of that claim, and recently, studies in adults have demonstrated that there has not been a statistically significant difference in the types or range of symptoms in adults throughout the pandemic.
But, what about children? You might be surprised. And, you might guess that if the same was true for children, we would be done with this blog post by now. You would be right. Of course, we all remember the refrain that COVID is nothing more than a cold or the flu and that in children it is even milder, as well as the widely held belief that of all the variants, Omicron is the mildest.
For those of you who might be a bit challenged by the Greek alphabet and trying to keep track of when each variant was prevalent in the U.S., I will provide you with a quick summary:
Wild-type virus (original) March 2020 – January 2021 (the virus did soon acquire a mutation referred to as D614G that significantly increased transmissibility of the virus, but this variant was not given a Greek letter designation)
Alpha February 2021 – July 2021
Delta July 2021 – December 2021
Omicron December 2021 – present
Researchers reviewed children under the age of 18 in Canada who presented to any one of 14 pediatric emergency rooms and tested positive for COVID-19 between August 4, 2020 and February 22, 2022. The children were followed for 2 weeks from the time of their emergency room visit. The SARS-CoV-2 variant the child was infected with was determined by sequencing of samples taken at the time of their emergency room visit.
Findings:
- The most common symptoms in children infected with the wild-type virus were abdominal pain, followed by muscle pains, abnormal sense or loss of taste, and then loss of smell. Musculoskeletal symptoms (muscle aches and joint pains) were most common in children infected with the wild-type virus as opposed to any of the subsequent variants.
- Children infected with Alpha tended to have the fewest number of COVID symptoms (median 5 symptoms), while children infected with Delta and Omicron tended to have the most.
- Children were more likely to have fever and/or cough with Delta and Omicron infections.
- Interestingly, conjunctivitis was most frequently reported or observed with Delta infections in children.
- Symptoms were most likely to be upper respiratory tract (nose and throat – runny nose, sore throat) in nature with Delta, but lower respiratory tract (lungs – chest pain, shortness of breath, wheezing or coughing up phlegm) with Omicron.
- Children with Omicron infections were most likely to have systemic symptoms (irritability, drowsiness, weakness, lethargy).
- Children with Omicron infections were more likely to receive chest x-rays, intravenous fluids, steroids and have a return to the emergency room.
- Despite all of these differences, the percentage of children with severe disease requiring hospitalization and even intensive care did not vary throughout the pandemic by variant.
- Loss of taste, loss of smell, and rashes were all less frequent findings in children infected with Alpha or Omicron.
- Children infected with Delta were also the most likely to have a co-infection.
A few thoughts from me. It has been concerning to me that COVID-19 has been minimized so much. First of all, in this study, across the 18 months of evaluation, 11.4% of children that were seen and evaluated in the emergency room ended up hospitalized and 0.6% ended up requiring intensive care. (Keep in mind, we don’t even know the long-term health effects that may occur in children.)
If we consider mild symptomatic COVID to be cases where the infection can easily be managed at home without medical attention; moderate infection to be those cases where medical attention and interventions are needed, but hospitalization is not; and severe infection to be those cases requiring hospital care or resulting in death, then we can conclude that for children, moderate symptomatic disease increased during Omicron, while severe disease remained constant throughout the pandemic.
You may be surprised that the percentage of children experiencing severe COVID-19 remained fairly constant throughout the pandemic, while clearly, for adults, we experienced more severe disease and overwhelming of our hospitals during earlier waves, particularly at the end of 2021 and beginning of 2022. I can’t state with certainty why that is, but I can certainly make educated guesses.
First, vaccines were available to adults for quite some time before those vaccines were available to children. Even once available to children, uptake of COVID vaccines in children has been much less than in adults, and frankly, in my assessment, COVID vaccine uptake overall has been abysmal. Second, adults benefitted from many COVID mitigation practices that were significantly underutilized in children. We have also known for quite some time that the immune responses of children, especially very young children, is different from that of adults. I don’t think we have quite worked out the differences in immune responses to SARS-CoV-2 in children and adults, but that may also play a role. Finally, I fear that as adults became more complacent about COVID since Omicron has become dominant, we are exposing our unvaccinated children even more than previously, especially at a time when variants are continually becoming more transmissible and immune evasive.
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