The unseen effects of covid-19 on children in Italy

Pediatricians describe what coronavirus took away from children in Italy

We have read and listened to it more than once these past months, and not without relief: children are less affected by covid- 19.  And when they are infected, they often have no symptoms or suffer from a mild clinical form: cold, fever, cough, vomiting and diarrhea. 

But while it’s true that the age group seems to be the least clinically affected by the virus, children and adolescents suffer indirect effects on psychological, social, and educational levels, especially the most fragile children - those with chronic diseases, and the poorest economically.

On 27 and 28 November, the Italian Association of Pediatrics will discuss everything related to children's medicine and how covid impacts the lives of younger citizens.  It is an extraordinary event, as the situation in question is out of the ordinary, and is an appeal from pediatricians around the nation to reopen schools.

The Numbers

“Since the beginning of the epidemic," says Alberto Villani, president of the Italian Association of Pediatrics, "the virus has affected the pediatric age less seriously than adults.  43,841 cases (3.6% of the total) have been diagnosed in the age range 0-9 years and 105,378 cases diagnosed in the 10-19 years (8.6%).  As far as symptoms are concerned, among the youngest children (0-1 year old) asymptomatic children are more than 6 out of 10 (64.3% of cases), those with mild symptoms make up 3 out of 10 (32%) cases, and only 3.4% show severe symptoms.  Between 2 and 19 years of age asymptomatic cases are more than 7 out of 10, the others are mildly symptomatic. Since the beginning of the epidemic the deaths recorded from 0 to 19 years are 8 (source: Istituto Superiore di Sanità).

A clinically acceptable virus for the smallest citizens

“With children it is less bad, and this initially surprised us: we feared especially for infants and the immunocompromised”, says Luisa Galli, head of the Infectious Disease Department at the Meyer Children's Hospital in Florence, and secretary of the Pharmacology Group of the Italian Association of Pediatrics.

Why are younger children less sensitive to covid-19? "We can only hypothesize”, Galli continues, “probably the most accredited, is one regarding how the mucus of the respiratory system of children, ACE2, i.e. the receptor to which the virus binds, is less expressed. This could explain why it cannot do the damage it does in the adult population, not even in children with cancer or immunocompromised diseases.  At Meyer Hospital we transplanted marrow to a girl with leukemia, while positive for the virus, and she also never had a major symptoms: this was a nice surprise.  Even the most physically fragile children did not pay a high price with covid-19".

But being less symptomatic doesn't always mean being better, and when the symptoms of covid are there, they must be treated, even in the youngest patients.  In what way? "With paracetamol for fever, as always. And avoiding dehydration in younger children with vomiting and diarrhea. Other therapies, such as cortisone should be administered in hospitals, in case of breathing difficulties or co-infection with other viruses".

"It was very fortunate that children showed reduced susceptibility to covid-19.  If this new virus had affected children like adults”, concludes Galli, “we would have had a huge problem, considering that in Italy, as in other countries, there are few pediatric isolation units and pediatric intensive care beds.  Let's think about it in time.  The next epidemic, even if we hope not to see another one soon, might not save the pediatric age".   

Children are always vulnerable

"They have not been clinically affected by the virus like adults, but children have had significant relational, educational and scholastic psychological effects”, begins Giovanni Corsello, Professor of Pediatrics at the University of Palermo.  “Because being a child is in itself a vulnerability. Then there are the most fragile children who have suffered even more from covid and lockdown: we are talking about those who suffer from chronic diseases such as diabetes, rheumatoid arthritis, kidney disease, bronchial asthma or genetic diseases, that make up at least 15% of the pediatric- age population”. 

Fifty percent of these patients need checks, diagnostic tests or special therapies, but during the lockdown period, they have had reduced or postponed access to the hospital.  "It occurred”, Corsello confirmed “for one out of every two children because the families feared contagion, and this has led to risks and complications, even fatal, the most striking case is that of children with diabetes 1 that risk ketoacidosis, a potentially fatal condition that can lead to coma".

According to Siedp (Italian Society of Pediatric Endocrinology and Diabetes), the number of severe ketoacidosis that occurs at the beginning of the disease has increased from 36% of the total in the pre-covid period, to 44% during the lockdown.  For almost one case out of two, access to the emergency room was late. According to Aieop, (The Association of Pediatric Onthology) in the period from March-May 2020, pediatric cancer diagnoses were reduced by 30% compared to the same period last year.  The most fragile children therefore paid double the price for the pandemic and lockdown: like all their peers, they paid for it in social and educational terms, but more than the others in health risks.

Emergency Room Avoidance

Across the board, according to Simeup (Italian Society of Pediatric Emergency Medicine), during the pandemic the average drop in pediatric users in the Emergency Room was 40%, with peaks of 80% in some areas of the country.  But hospitals are safe, pediatricians are keen to say - and families need to know this.

Increased number of stillborn babies

According to a study carried out in Lazio, but in line with other surveys conducted in other European countries, during the first wave of the pandemic, the birth rate, i.e. the percentage of stillborn children, increased three times.  This is not a direct cause of covid,  say pediatricians, but because women underwent fewer checks during the lockdown period.  The visits are considered necessary to find alterations during pregnancy, that can cause serious consequences if left unchecked.

Drop in vaccine coverage

During lockdown, children were vaccinated less, especially during the first wave. According to an Italian Association of Pediatrics survey, more than 3 parents out of 10 have postponed vaccinations for fear of covid infection, or because the vaccination centers were closed, at the risk of a possible resurgence of diseases such as whooping cough, measles, and meningitis. 

The problem is not only Italian: the World Health Organization, Unicef and Gavi, (Vaccine Alliance) have estimated that, as a result of the pandemic, at least 80 million children in the world are at risk of contracting diseases preventable with vaccinations.  According to preliminary WHO-Unicef data, for the first 4 months of the year there has been a substantial decrease in the number of children who have completed the 3 doses of diphtheria, tetanus and whooping cough vaccine.  This is the first time there is a decrease in 28 years.

Also read: The rollout of a Covid-19 vaccine this December now likely

Nutrition, lifestyles and inequalities

An Italian study on obesity of 41 children and adolescents with obesity confined at home last spring, showed that during the lockdown there was a significant increase in the number of daily meals and consumption of fried foods, red meat and sugary drinks compared to before the pandemic. Just as there was an increase in the time spent in front of screens, obviously to the detriment of physical activity.  "But there is another study, this time on amongst Spanish children and teenagers of normal weight that showed data that overlapped with the Italian one, in terms of reduction of physical activity and the increase of time spent in front of screens," adds Annamaria Staiano, Professor of Pediatrics at the University Federico II in Naples. "This second publication”, adds Staiano “also analyzed the socio-cultural factors related to the results, finding that the reduction in physical activity was significantly more marked in the children of foreign mothers or those with lower educational qualifications". 

As if to say that the covid pandemic is exploited onto the pandemic of incorrect lifestyles, which in turn is exploited onto the eternal plague of socio-economic inequalities. "That is exactly so, they are pandemics within pandemics: the socio-economic aspect is not secondary.  One of the risks related to pandemics and lockdown is the worsening of social inequalities, which are closely related to health: wrong lifestyles and nutrition in the long term are related to chronic diseases, first of all obesity, which are associated with increased morbidity mortality,” states Staiano. 

In Italy, there are more than 1,200,000 children in absolute poverty (Istat data), in Southern Italy 10% of families are in poverty.  "More attention should be paid to the risk that the pandemic worsens the condition of families who are already in difficulty, it is a matter of many children," concludes the pediatrician.  So many children that could increase: according to Save the Children by the end of the year, 1 million more children could slip into absolute poverty.

Reopening schools and safe places

"The dramatic increase in poverty is associated with quality of life, an increase in illnesses and disorders, and difficulties in the physical, emotional, cognitive, linguistic and social spheres, even during the pediatric age.  And the closure of schools”, explains Mario De Curtis, of the Italian Association of Pediatrics Committee for Bioethics,has amplified these critical issues because many students were excluded from distance learning due to the lack of PCs or connections.  Istat has certified that during the lockdown, 1 student out of 8 did not have a laptop for distance learning, and more than 2 minors out of 5 lived in houses without adequate space to study".

Also read: What to do if you come in close contact with a Covid positive person

According to the data of the Ministry of Education, disseminated students infected on 15 October were 5,793, 0.08% of the total, teachers 1,020, ie 0.13%, and the remaining school staff 283, ie 0.14% "data that testify that schools are safe places”, explains vice president of the Association of Pediatrics Rino Agostiniani.  “Covid infections are lower in children than adults and seem to follow the situation rather than guide it.  It is easier for an adult to infect a child than the other way around.  What is worrying instead, is the growing evidence of damage due to isolation: such as anxiety, sleep disorders, eating disorders.  The opening of schools is urgent to prevent the health and economic crisis from being accompanied by an educational and social one with heavy consequences for all children and adolescents”.

Health education for students

“The Italian Association of Pediatrics”, proposes Villani, “asks for the inclusion of health education as a teaching subject from kindergarten to high school, and is available to share the programs to be carried out.  Training citizens to be prepared on public and personal health issues would make everyone's health better, would facilitate the sustainability of our National Health System and would show significant savings for the state banks”.

A pediatrician’s cry to end violence against women

The Italian Association of Pediatrics has always been committed against all violence, and pediatricians have a very important role in identifying and reporting cases, not only towards children but also towards their mothers. "All women can rely on their pediatricians to offer concrete help in cases of difficulty", says Alberto Villani.  The Association of Pediatrics to say no to violence against women, and made a music clip on the occasion of 25 November, the International Day for the Elimination of Violence Against Women.