By Heather Haq

Throughout the pandemic, I have cared for kids admitted with covid-19 to the children’s hospital in Houston where I am a pediatrician. These children have included newborns with fevers who require a sepsis evaluation, school-age kids whose bodies are ravaged with inflammation associated with covid-19 in children, and tweens and adolescents with covid pneumonia who need oxygen and other respiratory support. I’ve cared for children whose entire families have been devastated by covid — sometimes the child was sick enough to be admitted but had no parent at their bedside because the parents were critically ill at the adult hospital down the street or, worse, had recently died of covid.

All the while, as both a doctor and mother, I’ve wrestled with a certain dissonance: There is this popular notion that covid doesn’t affect children — and my public health and epidemiologic training reminds me that on a population level, it’s true. The majority of children who contract covid-19 will be asymptomatic or have mild disease. But I contrast this with the reality of being a clinician at the bedside of children critically ill from covid and covid-related illnesses. These two perspectives battle in my brain as I make risk assessments for my own school-age child. One thing that terrifies me as a parent is that we can’t predict why some children get so incredibly sick from covid while others have mild disease; we don’t know why some go on to have lingering debilitation and symptoms for months, and others make quick recoveries.

What I do know is that in this moment, as the highly contagious delta variant becomes the predominant strain circulating and we enter another covid surge, I am more worried for children than I have ever been.

First and foremost, this is because the high transmissibility of the delta variant will translate into a greater number of children being exposed than before, which will lead to a greater number of children infected. Even if the delta variant is no more virulent in children than the original virus was, the sheer numbers will translate into more children being admitted to the hospital with covid and covid-related illnesses. As school reopenings coincide with the growth of the delta variant, I worry we will see large outbreaks in school settings that we didn’t see with less-contagious versions of the virus.

I wonder, if more people saw what I see at patients’ bedsides, would they do more to protect children? I talked with one mother who wondered whether she could have done something to prevent her child from ending up sick in the hospital with covid. I recall providing emotional support — in addition to oxygen, steroids and remdesivir — to a teenager admitted with covid pneumonia who was grappling with the recent deaths of multiple family members with covid. His life had turned upside down in a few short weeks.

Over the course of the pandemic, our hospital system has diagnosed more than 15,000 children and adolescents with covid — a number that is trending up. About 10 percent of them have required hospital admission. Up to one-third of children admitted to our hospital have required critical care — including oxygen delivered through high-flow nasal cannula, noninvasive ventilation, and intubation with mechanical ventilation. When I discharge children from the hospital, I know that many of them have a long road to recovery, and many will require follow-up for cardiac clearance and long-term care in our hospital’s long-covid clinic. More than 300 children across the United States have died of covid since the beginning of the pandemic, according to the Centers for Disease Control and Prevention. Most children with covid will make a complete recovery, but up to 10 percent, including those with mild illness not requiring hospital admission, go on to develop months-long symptoms of long covid.

During previous covid surges, children’s hospitals in the United States experienced very low patient volumes compared with prior years because people were not seeking routine medical care or elective procedures. We could easily handle the influx of children with covid because we also were not seeing much of the common viruses of childhood, such as respiratory syncytial virus (RSV) or influenza, which typically keep children’s hospitals busy all winter. During previous surges, children’s hospitals across the country were able to serve as pop-off valves for adult hospitals overwhelmed with covid admissions, in many instances stepping up to admit and provide direct clinical care to adult patients, or lending equipment to adult hospitals.

What’s different this time is that children’s hospitals are also dealing with an unusual summertime surge in respiratory viruses, including RSV, which causes acute illness in infants and toddlers. Our hospitals are seeing a huge, sustained influx of patients with RSV — who often need oxygen and respiratory support — and we are busier at our baseline than at other times during the pandemic. I worry how children’s hospitals will handle a covid surge on top of the RSV surge, which will stress hospital systems and staff.

Adding to my concerns as a pediatrician is that our society is dealing with covid fatigue. Children younger than 12 remain ineligible for vaccination, but people are tired of following mitigation measures and eager to get back to normal life. Too many eligible adults and adolescents over 12 years of age remain unvaccinated. One important step that families can take to protect their children of all ages is to ensure that all eligible household members over age 12 are vaccinated; it is heartbreaking to care for children hospitalized with covid when I know this could have been prevented.

I am often approached by friends, family members and neighbors facing the difficult decisions that I also face as a pandemic parent: How do we keep our children safe? I like to remind them that during the past 18 months, we’ve gained both experience and knowledge and developed tools and recommendations to help limit the spread of covid — all based on scientific evidence. Masking (including universal masking in schools), physical distancing, testing, contact tracing, quarantining and vaccinating do help. If we abandon these crucial tools now, we are putting our children in harm’s way.