When P Manjula’s 7-month-old grandson started feeling warm to the touch two weeks ago, her family descended into panic. Fearing the worst, they rushed him to a private hospital in Mysuru, where doctors advised them to visit the fever clinic. At the Primary Healthcare Centre (PHC), a rapid antigen test confirmed their fears — the baby tested positive for Covid-19.
A medical officer at the PHC describes the heart-rending scene of Manjula, unable to contain herself, rushing to take her grandson into her arms, trying to ease his discomfort. “When a baby is suffering, even thinking about social distancing, safeguarding yourself is incredibly difficult. I could not contain myself,” Manjula said.
Paediatricians are now reporting that the number of Covid-19 cases in children is on the rise in the second wave.
Since January, 11.5% of the cases reported in India were in the age group of zero to 20 years. Between March 13 and May 21, 41,404 cases were recorded in children between zero to nine years and 1,09,736 cases among children between 10 to 19 years of age. “The proportion of children affected by Covid-19 was 4% (in India) during the first wave. Now it is between 10 to 20%,” said Dr Asha Benakappa, the head of the Department of Paediatrics, Dr Chandramma Dayananda Sagar Institute of Medical Education and Research, Bengaluru.
Like Manjula P, the families of many children are already rushing from one doctor to another, with their hearts in their mouths. Dr Karthik Nagesh, Chairman of Manipal Advanced Children’s Centre and Chairman of Neonatology, Manipal Hospitals sums it up, “If children get afflicted, it will be very unfortunate.”
Dr V Ravi, a virologist, and other paediatricians say that Covid-19 infections in children will really start to climb during the third wave.
In most instances, the infection alone is no cause for alarm. Manjula’s grandson, for instance, recovered in two weeks under the care of his parents and with prescribed medications. Dr Nagesh estimates that in 85-90% of cases, children will recover without any need of hospitalisation and that not many complications are likely.
But even a low percentage of serious cases can overwhelm the healthcare system if there is no foresight and preparation.
Vaccination
“We have been vaccinating children for a range of illnesses. It can be a powerful strategy of controlling the spread of the virus,” said Dr Benakappa.
However, banking on the vaccine to stave off a possible third wave might not be the best strategy. In an interview with DH, Dr Ravi estimated that the third wave would hit two or three months after the second wave ebbs. It is unclear if vaccines will be available by then. On May 13, Niti Aayog member Dr V K Paul announced that the Drug Controller General of India had approved Phase II/III trials for children between 2 and 18 years of age and that Bharat Biotech would commence trials in about 10 days from then. AstraZeneca has also been conducting trials on children between 6 and 17 years of age in the UK.
“If everything goes well, we can perhaps start expecting vaccines for children around August — if we do all the right things, that is,” Dr Ravi said. Until vaccinations are available and the country can launch a full-scale inoculation drive for children, trying to control the spread of infections is essential.
Dr Benakappa is among many paediatricians who believe that there needs to be a shift in the way the public follows Covid Appropriate Behaviour (CAB), like wearing a mask, washing hands regularly, avoiding touching one's face and maintaining social distancing.
Rakshitha Shrikanth, a 44-year-old mother of two is also frustrated with some parents’ behaviour. “Even those who are aware of the extent of the spread of the virus are still very casual about following recommended measures,” she said. Her 16-year-old daughter has asthma, and she worries about her welfare.
There has been an increase in the number of children infected in this wave because of the sheer number of people who have tested positive, said Dr M L Keshavamurthy, the nodal officer at Indira Gandhi Institute of Child Health, Bengaluru.
Between May 7 and 14, the test positivity rate (TPR) in Karnataka remained at a steady 32%, leaving health workers exhausted.
“To prevent the third wave from affecting children, you have to immediately vaccinate as many adults as possible as they would be the primary source of infection for children” emphasises Dr Nagesh.
Prepare for the worst
Even while reducing the intensity of the third wave, public healthcare specialists say India has to prepare for the worst-case scenario.
"Learning from the experience of the second wave, we have to create a paediatric Covid task force to help triage and create a good number of beds for children in various hospitals and ramp up other facilities," Dr Nagesh added.
Given the population and proportion of children in it, Dr Keshavamurthy estimates that Bengaluru alone would need 500-1000 ICU beds with oxygen facilities for children.
Dr Premalatha R explains that while ICU beds for adults can be used for adolescents, “Children will need ventilator tubes that are smaller, that will fit their face.”
Right now, most paediatric hospitals work on referrals as tertiary care centres. There is no record of the availability of ICU beds and oxygen facilities that are suited for children.
To ensure facilities are easily accessible, Dr Keshavamurthy suggests putting in place a three-level, decentralised system.
“We should allocate triaging centres for children at the municipality level, where doctors and other health staff can be trained in a common protocol to monitor and classify children according to severity,” Dr Keshavamurthy said, adding that doctors and health staff should be able to identify and predict in advance which children will need intensive treatment, and accordingly move them then to level-2 or level-1 hospitals with more healthcare staff and equipment.
Treatment protocol
During the first wave, Dr Athreya delivered an infant whose toes and fingers were blue in colour due to Multi-system Inflammatory Syndrome (MIS-C), a rare consequence of being exposed to Covid-19.
At that point, the medical team did not know that the mother had Covid-19. “It is important that we create awareness and share such cases so other doctors can recognise and treat it,” he said, adding that maintaining a registry in ICUs and HDUs (high dependency units) could also help in the early detection of patterns.
“By the time we see a surge in cases, a uniform medical protocol must be put in place. The Indian Academy of Pediatrics' statement on Covid-19 management can be used,” Dr Athreya suggested.
It is recommended that there is one paediatrician for every 10,000 children. India would need a total of 1.36 lakh paediatricians. The Indian Academy of Pediatrics claims to have 90% coverage of paediatricians. In total, it has 31,176 members.
Doctors also warn that a lack of trained professionals who can operate this equipment can also pose significant problems. Training people to be able to do these tasks is important, said Dr Nagesh, “We should see and get as many volunteers and healthcare workers recruited for this activity because we don't know how big this onslaught will be and how many children will get affected.
Volunteers and healthcare workers who can sensitise the general public, pick up early symptoms and signs and help monitor children at home are also essential, he adds.
Healthcare providers also need to keep in mind that the treatment of children may need a different kind of care that may challenge the existing protocol that we have in place.
“A peculiar thing about children below six years of age is that they have to be accompanied by the mother while receiving treatment,” said Dr Benakappa.
Social separation anxiety among young children is a normal stage of development but can be particularly intense in stressful situations. “If the mother has also tested positive or if she has been vaccinated, she can accompany the child after following Covid Appropriate behaviour, but what if she tests negative? A decision needs to be made regarding this,” said Dr Benakappa.
Vulnerable populations
Like Rakshitha’s daughter, many children may also have conditions that could make them more vulnerable to the virus. Dr Athreya explains that children with obesity, asthma, diabetes, babies who are born premature and suffer from other comorbidities, have the potential to develop more intense symptoms. “There should be a way for such children to be identified and for them to be able to access intensive care when they need it,” he said.
The high level of malnutrition in the country and in Karnataka, as indicated by the National Family Health Survey of 2019 - 20 is a worrying factor as well. (See table)
“Malnourished children may also have weakened immune systems, which makes it more likely that they would develop symptoms more quickly than healthy children,” said Dr Premalatha R, a professor of paediatrics.
Doctors are also sounding alarms that children who are exposed to the Covid-19 virus also seem vulnerable to Multi-System Inflammatory Syndrome (MIS-C) — a condition where different parts of the body can become inflamed, including the heart, lungs, kidney and brain.
It usually manifests in the form of rashes, joint pain, dullness and loose stools, explains Dr Keshavamurthy.
About 1% of children can be affected by this syndrome, says Dr Asha adding that “such cases require high-level care with ventilator support and even cardiac care.” Even children who recover well can develop post-Covid complications like MIS-C three to four weeks after infection, which parents should be on the lookout for.
As both parents and children experience anxiety about what the third wave could pan out, Dr Ravi said, “When we do not know many things, the best strategy is to be prepared.”
Preparations will never go to waste, particularly, infrastructure for our children. “Our children deserve it,” he said.
(With inputs from Prajwal Suvarna)