26/05/2021
Mani’s Story:
Six year old Mani is my daughter’s classmate. They have never ever met in the real world but they watch out for each other in the virtual classroom. Perhaps the feeling of camaraderie comes from the fact that both are introverts. While the rest of the students are trying to get their voices heard these two are trying to hide in the camera’s blind spot.
When Mani walked into my consulting room she looked worse for wear. She greeted me with a polite good morning auntie. Though a little scared on seeing my daughter’s friend in such a state I mustered up enough courage to ask her mum what brought them to my place. The complaints were usual – fever for a day, little cough and blocked nose. The generalized feeling of weakness made it difficult for the poor girl to get up even during meal times. For the past twenty four hours she had been exclusively on liquids as her appetite did not permit solid intake.
The air suddenly became heavy with unspoken words and when it was no longer possible to ignore the elephant in the room I said the word COVID. (Every time before saying the word I remember what J.K Rowling taught me when I was a little girl – not saying out the name aloud only increases one’s fear of the entity.) So there I had said it. Just like any other parent, Mani’s mum and dad did not wish to think about the concept in relation to their daughter. I tried my best to allay their anxiety with facts (I admit it is difficult at times).
Kids more than one year of age are actually less likely to suffer from grave complications of the infection particularly like in Mani’s case when they have no underlying morbidity, no heart or liver or lung or kidney disease, no malignancy, no chronic infection like tuberculosis, no morbid obesity, no condition leading to immunocompromise and when they are well nourished.
Many theories have been put forward to explain the increased severity in adults:
(1) Scientists speculate that perhaps as our age increases the lining of walls of our blood vessels (endothelium) gets damaged and it is mostly intact in children, also adults may have altered clotting function.
(2) Different distribution and affinity of certain receptors like angiotensin converting enzyme 2 receptors which are believed to play a major role in the disease process.
(3) Preexisting antibodies and cell mediated immunity against the virus which may lead to exaggerated immune response.
(4) Aging of immune system and presence of chronic infections like cytomegalovirus.
(5) A higher prevalence of comorbidities like diabetes, hypertension, chronic renal or hepatic disease.
(6) Lower levels of Vitamin D
Children may also be naturally less prone to the severe consequences perhaps due to:
(1) Different maturity of immune system (adaptive and innate)
(2) More frequent recurrent and concurrent infections
(3) Preexisting immunity to corona virus
(4) Differences in the bacterial flora of the body
(5) Higher levels of melatonin
(6) Protective off-target effects of live vaccines
(7) Less exposure to SARS CoV2
If many of these statements sound contradictory it is because they are. Like I said they are just speculations not adequately proven by research.
Coming back to Mani, I asked her parents whether anyone else in the family had COVID like symptoms in the past 10 -14 days? Even if not treated, did anyone have even a mild fever, cold, cough, body ache, diarrhea, vomiting, pain in the abdomen, weakness, anything at all out of the ordinary? SARS Cov2 is a sneaky virus. (There is an ongoing joke in the medical community that it can lead to any known medical condition except pregnancy and fractures and we are not so sure about the later. In all seriousness it is because the virus affects the immune system – it is like the enemy infiltrating our defense system you feel caught up in an Agatha Christi or Dan Brown novel you can’t trust anyone and the friendly narrator turns out to be the culprit.)
Gradually as they started accepting the reality, Mani’s father told me that his dad had been running a little fever for the past week, they had consulted a doctor who had advised admission due to lower oxygen saturation and CT scan showing a few lesions (as per history) – the COVID report (RT PCR) was pending. Currently they were looking for a hospital bed. They were in denial. They were sure that the grandfather was suffering from asthma or some bacterial infection anything at all except the dreaded virus. A mother of a 6 year old myself and with my parents in their sixties I can understand their fear. But I want to tell all the adults out there that the only saving grace of this pandemic has been that it has so far been relatively kind to our children.
Yes, more children are affected as compared to the first wave and that is mostly because total number of cases is more. They are more severely affected as compared to last year but it is no reason to panic. The numbers are still much less as compared to adults.
We do not know the exact numbers but experience has taught us that many of them will remain asymptomatic. Out of those who develop symptoms majority will have only mild symptoms not requiring admission to a health care facility.
Then there are a few which do require to be admitted like those with poor intake of food and water, increased loss of water in diarrhea, fever not responding to the usual oral fever medicines. Here the situation becomes a little tricky – where to admit them? It is easier to manage adults at home as compared to children especially less than 5 year olds because we cannot explain things to them ( why they must eat or why they need to rest) and many times we don’t understand what they want to express (what exactly is troubling them). In other words children need to be sometimes admitted even if they are not as sick as the adults and so have a huge chance of pulling a full recovery as compared to adults who are only admitted when they become very sick. Now the second question arises as to where to admit them. It is very difficult to manage a child in the absence of doctors and nursing staff trained in taking care of the little ones. Until now the designated COVID centers did not have pediatricians or nurses trained in pediatric care but now that is not the case.
That leaves very few children who are indeed severely affected by COVID usually those with co-morbidities. They are the ones who need intensive care.
First things first – should Mani be tested for COVID? By testing if you mean RTPCR yes definitely. I can give 3 good reasons:
(1) There is a lot of psychological and thus practical difference between how we handle a suspected and a confirmed COVID case with regards to monitoring and isolating in particular.
(2) When we have a proper diagnosis we can relax our watch for alternate causes.
(3) It takes a couple of days before we get the report after we send the test. If at all we need to admit the patient or give them certain specific medicines we may need a positive report.
What about blood investigations and CT scans? We can wait and the decision can be taken on a case to case basis. If the fever or other symptoms are persistent we might have to do blood reports. As far as CT is concerned we try to avoid it unless there is a problem in breathing or drop in saturation.
I prescribed the medicines for a case of suspected COVID. Surprisingly the dreaded infection needs only basic therapy for management. An antipyretic namely paracetamol for fever and a cough syrup. I added a supplement – with vitamin C, vitamin D and zinc for whatever it is worth in the recommended doses. I admit that it’s efficacy is not proven but then they are not shown to cause any untoward effects when they are not given in excess.
The key to successful management however is thorough monitoring and early intervention. (The key to giving the best possible treatment to a patient is doing the right thing at the right time to a right degree – also known as the Goldilocks principle, “Things should not be overdone or underdone they should be just right.”)All suspected or confirmed COVID cases need to have the following monitored: These are for guidance only – please discuss with your pediatrician in case your child develops COVID related symptoms.
(1) Temperature – Inform the treating doctor if the temperature as measured by a digital thermometer in the underarm remains above 99 degree Farenheit especially when you are giving anti fever medicine round the clock at 4 to 6 hourly intervals.
(2) Respiratory rate – This depends on the age of the child. Any reading above the normal for age as given in the following table should be brought to the treating doctor’s notice.
Age Respiratory Rate (No. of breaths/min)
Up to 1 month 30-60
1 month – 24 months 30-50
2 years -3 years 25-40
3 years – 5 years 20-30
5 years – 12 years 16 -25
More than 12 years 15 -22
The best time to count the number of breaths a child is taking is when he/she is sleeping or at rest. Expose the chest fully before counting. An easy way to do it is to take a video in your mobile of the child’s chest movements for one full minute and then count the number of breaths. In case of any confusion you can send the video to the treating doctor.
(3) Saturation (with the help of a pulse-oximeter) :
- Use a good brand.
- Ensure that the battery is not low.
- Keep it on the child’s finger for one full minute before noting down the value.
- Learn to differentiate between the saturation and the pulse values.
- In infants (less than 1 year) measuring in the great toe of either foot is easier than trying to do so in thumbs or fingers.
The saturation should be more than 94% according to current guidelines at all times. Measure especially after the child has done some physical activity – in older kids after 6 minutes of exercise just like in adults.
(4) Pulse (with the help of a pulse-oximeter) :
Take care of all the points mentioned earlier. The pulse-oximeter will show saturation and pulse at the same time but they will be labeled.
Note down the pulse rate. It varies by a few beats from second to second but one can easily know the approximate value just by looking at the screen. If the pulse rate is falling out of range for a given age it should be brought to the doctor’s notice:
(The term heart rate is used in place of pulse. They are not the same but for practical purposes we can take these terms to be synonymous. )
Age Heart Rate (beats/min)
Up to 1 month 120 -170
1 month – 24 months 100 -140
2 years -3 years 90 – 130
3 years – 5 years 80 – 120
5 years – 12 years 70 – 110
More than 12 years 60 – 100
(5) General feeling of wellbeing :
Asking the child and trying to assess how he or she is feeling, is essential. Things like improved appetite, playfulness, a certain glow on the face are amongst the earliest and are potentially the best indicators of a child’s recovery. Conversely any deterioration in the general feeling of wellbeing signals an impending or current problem.
Ideally monitoring of these parameters should be done at least 4 times (6 hourly) in a day.
Mani’s mum wanted to know was there any role of alternate medicine in COVID management.
Pranayama and Yoga have definite benefit. The beauty of Suryanamaskar is that it is effective and easy. These should be done at least for 30 minutes total in a day.
Steam inhalation likely works and when done with care it does not hurt anyone.
Kadhas and so called Ayurvedic potions I am not so certain about. It is a vast topic about which I as a practioner of allopathic medicine don’t claim to have any knowledge of.
A few other fun activities that I usually tell children to do are blowing through a straw in a glass filled with water, blowing soap bubbles and inflating balloons. All due care must be taken to prevent a spray of viruses from happening – an older child can easily do these alone.
Mani’s parents visibly relaxed for now they realized that there was much that they could do. And that is what helps us the most – it is the feeling of helplessness which hurts the most. As we understand this illness more and more we are coming out from the initial fear that had paralyzed us. This is raising our mental strength and morale. The human race has survived many challenges we can do it this time too. But let this be a lesson to all of us – survival of human civilization is impossible without coming in conflict with nature – however there is a delicate balance which we must not allow to tip over at all costs. Otherwise the cost may be unbearable.
As is routine practice for all suspected or confirmed cases of SARS Cov2 infection we started monitoring Mani by video calls once every day for 10 days since the appearance of the first symptom. She was afebrile in 2 days and her monitored parameters remained in the normal range. Then on the eighth day we were in for a happy surprise. Mani’s mum called us to say that she was having a fever of 101.2 degree Farenheit. Now reappearance of fever is a bad sign. We were worried but an experienced nurse had the presence of mind to ask her to see whether Mani was warm to touch and when her mother said no she asked her to get a new thermometer and check again. It turned out that she did not have fever after all. This incident reinforced for us the fact that panic is the biggest enemy and when we move ahead in a systematic manner we can overcome the biggest of challenges.
As you must have guessed Mani is absolutely fine now. Her grandfather and later her grandmother had to be admitted for a week and 20 days respectively but both have managed to attain a full recovery.
What happens now? Can Mani or her family get reinfection? What can they do to better protect themselves? Will the COVID that they had acquired have long term consequences?
Yes they can get reinfection especially by a different or mutant strain of the virus. At present their best bet is to get vaccinated (Mani’s vaccination will have to wait until vaccine use is authorized in children), wear masks and maintain social distancing.
Nobody knows what effect this novel virus will have on us as a species but certainly we can neither afford to ignore it nor can we live in constant fear. We need to mend our nature damaging ways, stop trying to control nature in general and understand how best we can live in harmony with nature without wasting our precious resources. We should stop all unnecessary use of medicines and antibiotics, wastage of water and energy resources, pollution and killing of animals and plants which is leading to their extinction. We should learn the workings of our body it’s basic physiology. We have to keep in mind that we are a part of nature and not above it. Any change which we make is likely to backfire on us, it has taken millions of years of evolution for our body to adapt to the surroundings and any sudden change may be damaging. Next time our luck might run out!
References:
AIIMS Clinical guidance for management of COVID 19 (Version 2.1)
AIIMS guidelines for home isolation
COVID 19 management for 1 month -19 years old: Statement by Indian Academy of Pediatrics (April 2021)
