School's Open and Kids Are Getting Sick: Should Our Approach Change?

Interviewer: Laurie Scudder, DNP, PNP; Interviewee: Katie K. Lockwood, MD


October 05, 2020

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School's back in fits and starts, live, remote, and hybrid. But now on top of COVID, kids will go back to having all of the other things kids have: colds, flu, rashes, asthma flares. How should our approach change during a pandemic?

Medscape spoke with Katie K. Lockwood, MD, a primary care pediatrician at Children's Hospital of Philadelphia (CHOP) Primary Care and host of Primary Care Perspectives: Podcast for Pediatricians, about her approach.

A recent study reported on the clinical presentation of children with SARS-CoV-2. In this admittedly small sample of 192 kids, only about half of those with acute SARS-CoV-2 infection had fever. Most other symptoms, if present at all, were nonspecific. So my question is, can these kids be distinguished from those with a garden-variety upper respiratory illness (URI) or flu? How do you think these ill children should be evaluated?

I think you're hitting on one of the biggest issues heading into the fall. Many of the symptoms of COVID-19 overlap with those of other common respiratory infections. However, the loss of taste and smell, although it's not always there, is fairly unique to COVID, so that can help distinguish when it is present. Cough is part of COVID, but certainly you can see that with other respiratory infections. However, shortness of breath or difficulty breathing is less common with typical URIs. It's not a slam dunk that the child has COVID if they have shortness of breath, but I do think it would push me a little bit more in that direction.

Most of the cold symptoms that we see with our usual fall and winter viral illnesses are upper tract, notably nasal congestion. Although kids may say, "I feel like I can't breathe," what they usually mean is, "I can't breathe through my nose." That's a lot different from the feeling of not being able to breathe because you actually can't get air into your lungs. The caveat is that kids with asthma may say that, and that will add an extra layer of complication to this picture.

As my infectious disease colleagues have taught me, there is not, unfortunately, a simple checklist of symptoms to distinguish among COVID, a common cold, or the flu. Kids can have lots of variable symptoms that can look like COVID, and not every child with COVID will present the same way at all. That really is where that skill of a pediatrician who's taking into account all of the symptoms, as well as the context, to determine risk and need for testing is critical.

The context here is extremely important because we know that risk changes by geographic area or contacts with other people. Obviously, children who are in virtual school and haven't come in contact with anyone are less likely to get sick.

What should be the response from schools if a child goes to school seemingly healthy in the morning and begins coughing and sneezing in school?

I think similar to any other year, if a child becomes ill at school — fever, a lot of coughing, shortness of breath — then their parents should be notified so they can be sent home. The particular details of where a child remains physically in the school while they await pickup — an isolation room, the nurse's office, a separate space — is up to the school and the guidelines from their State Department of Health in terms of what they do with that child in the classroom.

I do think that schools need to be more vigilant this year. Someone who's coughing, who in the past might have been able to explain that it was "just my allergies," warrants a little more investigation. We need to figure out whether this is really true, that this is just something that's their routine allergies or if they're sicker, and I think that warrants a phone call to the parents so that we can start that discussion.

What about the kid who has been seen by their provider and perhaps had both COVID and influenza testing? What would be your advice?

There are two groups here: the kids who get tested and those who do not. I'll start with the ones who get tested. If their pediatrician determines that they needed to be tested for COVID and the testing is negative, they can go back after they're fever-free without medication for 24 hours and symptoms are improving — maybe not 100% better, but going in the right direction. If the COVID test is positive, then they're home for 10 days from the date of whichever came first — the test or onset of symptoms — and fever-free with improving symptoms.

The other category are kids who did not warrant testing. Perhaps the child was sent home from school with a fever and is determined to have an alternate source for the illness that is not COVID. Let's say the child is found to have a urinary tract infection (UTI); then we are less worried about COVID. Because there are still going to be other common illnesses happening in kids, guidance about school return should be specific to that diagnosis. For most things, it's fever-free for 24 hours.

But what about the child who does not have a clear reason for fever and is not tested for whatever reason — maybe a lack of availability of testing? I certainly do not wish to say that every child needs a test to return to school. I know there are going to be a lot of people who want that test because it might get them back to school a little bit faster. But in some cases it won't, because the test takes so long to come back depending on where you are. Returning to school for these kids is tricky.

If there is concern for COVID, owing to symptoms that are in line with COVID or an exposure history, then we are going to recommend that they stay home for 10 days from their symptom onset and be fever-free for 24 hours. It's really almost the same protocol as for kids who were COVID-positive on diagnostic testing. We must make sure that if they do have COVID and we just don't know it, they are not spreading it back at school. Although that is a lot of time out from school and work for the parents, it's really what we need to do to keep everyone else safe.

If seeing a child to evaluate for COVID, should pediatricians advise the family to also quarantine?

It's tricky. Most kids will have, at most, mild symptoms. In many cases, it may be that the parent is the one that was sicker and sought care first and then the child was tested later. Did the child have very few symptoms, not enough to raise any suspicion, and actually give it to the parent as the index case, or was it the other way around and the child's illness was secondary? Data obtained before school openings suggested that the parent is more likely to be the primary case in a family. That makes sense with schools closed. Parents are the more likely ones to be out, whether shopping or at work, and to be exposed. We don't know what it's going to look like once kids are back in school. With schools and daycares reopening now, there are more cases where the child is the index case. This is something that we will have to closely monitor as more and more children return to school.

Whenever we advise a child to quarantine, we also ask their parents to do the same. Unfortunately, the quarantine for parents is actually longer — at least for parents of children who are COVID-positive or whose status is unknown. The quarantine for parents starts 10 days after the child's symptoms started or, in the case of a child who is truly asymptomatic, the date on which the positive test was conducted. Because during that 10-day period, the child can be spreading COVID to the parents, and so we need to wait for that child's infectious period to be over for the parents' quarantine to start. In some cases, it could be as long as 24 days for the parents to be out of work and isolated at home. It is a long quarantine for parents.

If the child ends up being negative, the parents' quarantine is over when the child's is over.

As a pediatrician, I'm not treating the parents. We inform parents that quarantine is recommended, but we always advise the parents to talk to their own healthcare providers about their individual risks. If they were exposed to COVID, because they have their own medical histories, they need to talk with their providers to make sure that they're safe.

In my practice, we provide parents with a work note that explains the recommendation for quarantine to their employers. It can be hard for employers to understand why a parent needs to be home that long, and so we want to help protect their employment by explaining this recommendation.

Certainly, spread in the family is more common because you're in close, intimate contact with each other for long periods, which makes it higher risk for everybody.

Reports of stigma toward healthcare workers, whether or not they provide direct care to patients with COVID, have been seen worldwide. Is there any evidence that children who are suspected of being infected will face similar issues with potential for bullying, isolation, and other fallout?

I'm really hopeful that people will see that we're most successful in this pandemic when we work together to keep each other healthy. Fortunately, I have not seen or heard of children in my practice being bullied for having COVID. I'm suspicious that this is more of an adult issue and that there may be some of that on the parents' side.

I am concerned, though, about social pressures on kids to not wear masks. Again, that could come from parents and adults in their lives. I think that we need to celebrate each other for wearing masks, particularly in settings where it's not the popular opinion. I know when I see my patients, I always compliment their masks, like, "Oh, cool mask." Because I really want them to see that this is a good thing that they're doing and they're helping to protect their community, if not even themselves.

I think also as a community, we need to empower each other to do more self-monitoring, and self-quarantining if we have symptoms. This is not the time to send a child with sniffles or a stomachache to school with the plan that the nurse will call if things get worse. We should hold each other accountable. This is why I really applaud schools that are not penalizing teachers or students for staying home — for example, allowing them to flip back and forth between in-person to virtual curriculums. We really need to encourage everyone that's being brave enough to stay home and admit to not feeling well. That is what's going to keep everybody safe. If we support people in those decisions, I'm hopeful that we won't see the bullying that you mentioned.

Whereas it is clear that children with immunosuppression for whatever reason are at higher risk, what about kids with other comorbidities? What is your advice to families of children with diabetes, asthma, or other chronic conditions? Is it different from what you are telling families of kids without these significant conditions?

You're right that we all have different risks from illnesses. That is the same with COVID. Children who are immunosuppressed or have significant chronic disease are at increased risk. If those children have the option of in-person school, then the risks and benefits should be discussed with their pediatrician and any other provider caring for that child.

One key point to emphasize about children with asthma is that we are not seeing an increased risk in most children with well-controlled asthma. I've not been advising those children to do anything different from other kids. They should weigh the pros and cons of going to school like everyone else, despite their asthma.

The other point to make here is whether or not there are high-risk family members. Although most children are pretty healthy and their risk may be low, we need to consider what would happen if that child brought COVID home to other family members who might have chronic diseases and comorbidities that put them at risk. Intergenerational households are a particular concern.

Much concern has been raised about the drop in reports of suspected child abuse and neglect as a result of teachers, often sentinel reporters, not being able to actually see and interact with their students. Do you think the opening of schools should trigger a move away from telehealth and toward in-person visits with children?

It's so important that we discuss this, because we should all be looking out for the safety of children. I agree that the reopening of many schools will help children to reach out to a safe, trusted adult. Pediatricians also serve in this role. That's one of the many reasons that routine preventive care visits are so important. Most pediatric offices are already open and welcoming patients. The message from the American Academy of Pediatrics has been clear, that we should continue to provide preventive care and immunizations during the pandemic.

In my practice, telemedicine is a valuable option for those who cannot or do not need to come to the office, but it represents only about 10% of our overall visits at CHOP. It can help us to maintain social distancing in the office for those who do need to come in person.

When used appropriately, telemedicine can be a really useful adjunct to the in-person care we provide. It is, though, certainly more challenging to pick up some of the signs of such things as abuse when you can't see and examine the child.

Although the data are not definitive, anecdotally, many mental health professionals, pediatric clinicians, and parents report that stress, anxiety, and depression have all skyrocketed in kids since widespread shutdowns in March. For kids who are worried about returning to school, what are you telling parents?

I think there are different parts to the question. First, I agree that the pandemic has certainly led to an increase in mental health concerns in pediatric patients. As pediatricians, we need to help identify and support these kids and help them access appropriate mental healthcare.

Second, there is this group of children who are experiencing anxiety, but not necessarily at pathologic levels. Many of these kids are returning to school or sports after 6 months of isolation from their peers. For most of them, it is the longest they've ever been away from their social networks. When they return to school, it doesn't really look like what they are used to. Typically, children spend the night before the first day choosing outfits and talking about who will be their teachers. Now, they are talking about when to take your mask off and how often to sanitize hands. The teacher might be wearing a face shield and standing behind a Plexiglas wall.

That is a lot of change requiring adjustments. We all need to be understanding that there will be a range of emotions, from excitement and eagerness to apprehension and worry.

Some of the old advice about returning to school that we've always given still applies: Make sure your child gets enough sleep, eats breakfast, and follows a structured routine. That structure adds stability to the child's life and gives them a sense of ease.

In addition, we need to encourage parents to explain to their children that school will look different and why, focusing on the fact that the changes are to keep people safe and healthy. Then give kids a chance to ask questions. Because what they're worried about may actually be very different from what we think they're worried about. We want to make sure that we are providing them the answers that they actually want. Part of that as parents is checking our own anxiety, because if children see that their parents are anxious, that will create anxiety for them.

If parents are really concerned that their children's transition is out of what is normal for them — more significant separation anxiety, headaches, stomachaches — then they should communicate early and often with their child's teacher and, if available, a school psychologist.

And certainly reach out to their pediatrician. Although somatic symptoms can be related to this mind-body connection, they can also can occur with COVID. And this is another example of where the context becomes really important. A child whose belly pain only happens on Sunday nights probably doesn't have COVID. A child who is feeling short of breath in the car on the way to school, but who can then run around the house after school with no shortness of breath, is also unlikely to be ill. And a trusted clinician who knows the family and the child can help families figure that out.

A resource that I really like is the Child Mind Institute. They have resources for back to school, both in-person and virtual, because there are certainly still issues that kids experience from virtual school.

It is going to be a really busy fall. I know that our phones will be ringing off the hook. But that's our job. We want parents to reach out to us with their concerns. We want to help them navigate this new normal. We understand that no matter how much we wish things were different, the answer to their concerns will not always be very clear. Pediatricians are looking forward to helping families navigate this challenging time. That's something that we are used to doing, and it's something that we'll continue to do during this pandemic.

Katie Lockwood is a Philadelphia pediatrician, a mother of two children, a blogger and podcaster, and a chai lover. Follow her on Twitter

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