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    As school openings stir COVID-19 outbreaks, pediatricians sound the alarm

    Doctors say hospitals are filling with critically ill kids because of lax prevention measures at schools. Many are calling for mask mandates and vaccinations.

    Deanna Behrens, MD, a pediatrician at Advocate Children’s Hospital in Park Ridge, Illinois, discusses a COVID-19 patient with staff in the pediatric intensive care unit.
    Deanna Behrens, MD, a pediatrician at Advocate Children’s Hospital in Park Ridge, Illinois, discusses a COVID-19 patient with staff in the pediatric intensive care unit.
    Credit: John Martin-Eatinger, Advocate Aurora Health

    Several weeks into the new school year, fears among doctors that the return to classrooms would ignite COVID-19 outbreaks among children are coming true — prompting more pediatricians to step into the pandemic’s cultural rifts by citing schools as spreaders and urging them to require masks for students and vaccinations for staff. 

    Hospitals around the country are admitting more infected children than ever before, including many in intensive care units (ICUs) and on ventilators. In the third week of September, children accounted for nearly 27% of newly confirmed COVID-19 cases nationwide, according to a data analysis by the American Academy of Pediatrics (AAP) — an increase from the overall rate of about 16% throughout the pandemic. More than 200,000 pediatric cases were added during the week ending Sept. 23, the AAP notes, pushing the total during the pandemic to 5.7 million.

    “This surge has had the greatest impact we’ve seen on children and adolescents, without a doubt,” says Jim Versalovic, MD, PhD, interim pediatrician-in-chief at Texas Children’s Hospital in Houston, which on some recent days has diagnosed more than 200 new coronavirus infections in children. 

    The surge is hitting hospital staff with new challenges: pushing ICUs near or over capacity, delaying care for children with other ailments, complicating treatment because of co-occurring conditions, and bringing visits by family members who also might be infected.

    The challenges are emotional as well, because staff see the children as victims of decisions by adults to eschew measures to protect kids from the disease. At Medical University of South Carolina in Charleston, Elizabeth Mack, MD, chief of pediatric critical care, sighs and says:

    “We have a number of kids on ECMO” — extracorporeal membrane oxygenation, which uses a lung bypass machine to pump oxygen into and remove carbon dioxide from the blood of severely ill patients. “I just look at them and think, ‘This is all preventable.’ It tears up my heart.”

    In response, more pediatricians are publicly blaming the surges on schools that don’t mandate vaccines for staff and masks for everyone — and asking them to implement those public health measures. 

    “There’s evidence of transmission in the school environment,” Versalovic says. “We’re seeing more cases [adjusted for student population] in school districts without mask mandates.”

    In Ohio, Cincinnati Children’s Hospital Medical Center conducted a study showing that districts requiring masks only through sixth grade have infection rates nearly twice as high as districts requiring them for all students, while the Ohio Children’s Hospital Association called on school districts to require all staff and students to wear masks to curtail rising infections.

    And eight doctors who work in pediatric intensive care units (PICUs) around the country authored an op-ed for the Tribune newspaper group urging protective measures, including wearing masks in schools and getting vaccines, to curtail the onslaught they witness at work. “The system is not designed to take on this magnitude of preventable illnesses,” they wrote.

    “Many pediatricians are stepping into this space because it’s so critical. It’s affecting their patients’ lives,” says Sara Bode, MD, a member of the AAP’s Council on School Health.

    Fears fulfilled

    As school openings approached in August, doctors increasingly worried about how COVID-19 might spread among students because of a confluence of unprecedented conditions: The delta variant was surging around the country, many schools planned to open without mask mandates, many 12- to 18-year-olds and teachers had not been vaccinated, and there remained no approved vaccine for children under 12.

    “School became a ginormous topic” of discussion on ID Listserv, where hundreds of doctors, pharmacists, and other providers share information about treating childhood infections caused by microorganisms, says Jason Newland, MD, MEd, who oversees the project as a professor of pediatrics at Washington University School of Medicine in St. Louis.

    As communities publicly battled over mask mandates in schools (more than a dozen states banned the requirements), the AAP went in the opposite direction: In July, it tightened its “COVID-19 Guidance for Safe Schools” to recommend that all staff and students over 2 years old wear masks in school regardless of their vaccination status. One purpose of the guidance is to provide backup for pediatricians advocating for prevention measures in schools.

    “They can say, ‘This isn’t just my opinion,’” says Bode, a pediatrician at Nationwide Children’s Hospital in Columbus, Ohio. “This is the guidance of thousands of pediatricians across the country.”

    In the weeks after schools began opening, hospitals in many parts of the country were overwhelmed by record-setting numbers of children admitted for COVID-19. Florida, for example, was already experiencing a summer surge, “but with the start of school, things really got hairy,” says Kenneth Alexander, MD, chief of pediatric infectious diseases at Nemours Children’s Hospital in Orlando.

    While many factors contribute to COVID-19 outbreaks, studies released last week by the Centers for Disease Control and Prevention (CDC) show that recent outbreaks have been far more severe in schools that don’t require students and teachers to wear masks.  

    The correlation between school openings and the onslaught of child infections prompted CDC Director Rochelle Walensky, MD, MPH, to declare in late August that “large-scale quarantines or large numbers of cases are generally occurring in schools because schools are not following our guidance” for everyone 12 and over to get vaccinated and “for everyone, right now, to be masked” in school.

    More cases and complications

    Although most children with COVID-19 do not become sick enough to be hospitalized, according to the AAP, hospitals report seeing more infected children than ever — and more with severe symptoms — taking up more beds and requiring more complicated care.

    Several children’s hospitals report that the most severe illnesses are primarily in children under 5 years old and in older adolescents. (The youngest children appear to be catching the virus from parents or school-aged siblings or at day care or preschool.) Dayton Children’s Hospital in Ohio recently reached 98% of its bed capacity thanks to a surge in COVID-19 patients, including a 2-week-old suffering respiratory symptoms, says J. Michael Klatte, MD, chief of the Division of Infectious Disease. Klatte estimates that up to 40% of their recent COVID-19 patients have required time in the PICU.

    Many of the younger children are also bringing new complications. Their initial respiratory struggles indicate that they have COVID-19, the potentially serious respiratory syncytial virus — which has been booming in parts of the country — or both. That leaves doctors trying to determine which treatments to apply and children vulnerable to more harm if they have dual infections.

    “Both of them [the diseases] can cause severe infection in the lungs,” says Kari Simonsen, MD, pediatrician-in-chief of Children’s Hospital & Medical Center in Omaha, Nebraska. “We’re really worried about how those kids are going to do.”

    Adolescents’ symptoms continue to resemble the often-severe symptoms in adults, including heart and lung damage, Simonsen observes. In Dayton, Klatte notes that many of the adolescents have comorbidities, such as asthma and obesity, that complicate their care and recovery.

    Another complication of rising child caseloads is figuring out how to safely allow family members to visit patients, even in ICUs — a benefit often not afforded to adult COVID-19 patients for fear of spreading infections.

    “For young children it can be more dangerous for them to be alone, because that parent is going to be able to help keep them calm,” Simonsen says.

    Yet, as Alexander at Nemours Children’s Hospital notes, “Where there's a child with COVID, there is an adult with COVID.” 

    Some hospitals have tightened restrictions on how many relatives are cleared to visit and how many can visit at once, and they require visitors to wear masks. Given the emotion of having a critically ill child, Alexander says, relatives sometimes try to exceed the restrictions — to the point where staff have called security to prevent altercations.

    Speaking out

    Physicians are frustrated — not just because of the overwhelming demands for medical care but also because the children had little or no choice in protecting themselves from the disease: They are in enclosed environments where people don’t wear masks, and they are not old enough to get vaccines or their parents chose not to get them vaccinated.

    “I have yet to see a vaccinated kid” treated for COVID-19, says Simonsen at the children’s hospital in Omaha — echoing the assessments from several other hospitals. 

    “They’re suffering for things that adults are failing to do,” says Deanna Behrens, MD, a pediatrician at Advocate Children’s Hospital in Park Ridge, Illinois, and the lead author of the op-ed in the Tribune News Service syndicate. (She says the doctors connected through the Twitter hashtag #PedsICU.)

    To stop the spread of COVID-19 among children, pediatricians are increasingly trying to change decisions made by adults. Among the efforts and responses in the past few weeks:

    • In Wisconsin, nearly 500 doctors signed an open letter urging schools to implement mask requirements and other preventive measures. "We're seeing school districts make terrible decisions” by not requiring masks and appropriate distancing, pediatrician Amy Falk, MD, one of the signatories, told a local radio station.
    • A growing number of school districts around the country are mandating masks as student infections rise and doctors urge the requirements, such as the College Community School District in Iowa, which had previously declined such a measure.
    • Pediatricians and teachers held a public event urging South Carolina state legislators to repeal a measure to ban mask requirements in schools.
    • A father and son who were hospitalized at Medical University of South Carolina with COVID-19 — the teenager spent two weeks on a ventilator — became public advocates for the vaccinations they had once dismissed as unnecessary. They told their story to TV news crews at the hospital, urging everyone to get vaccinated.

    Mack, who was also an author of the syndicated op-ed, says doctors there wish the father and son had not been infected — but if more adults speak out about infections they’ve witnessed among children, “hopefully we can prevent more death and destruction.”