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--:-- Sean Rameswaram: At the outset of this pandemic, when it was just arriving in the United States, there was a sense that kids weren't really at risk. Since then, things have gotten less clear. Kids have died from COVID-19. And now there are reports that kids, not adults, are contracting a mysterious inflammatory illness related to COVID-19. Today, we're going to try and clear up some of the confusion surrounding kids and COVID with the help of Dr. Kevin Friedman. I'm at my office at Boston Children's Hospital. He's a pediatric cardiologist there, and he also teaches pediatrics at Harvard Medical School.
--:-- Sean Rameswaram: We started with this mystery illness. Yeah, so we're rapidly seeing this emerging syndrome of a highly inflammatory state in children and teenagers that has features that are often also seen in Kawasaki disease or toxic shock. It seems to represent a unique and new emerging syndrome in patients who either are COVID positive, or in some cases they're COVID negative, but have had COVID exposure.
--:-- Dr. Kevin Friedman: So how different does this Kawasaki disease look from COVID-19?
--:-- Sean Rameswaram: Kawasaki disease is a vasculitis. It's essentially an inflammatory disease of unknown metiology that usually affects children two to eight years of age and can cause severe inflammation of the coronary arteries, which leads to dilation and aneurysms. There's some overlap in terms of patients presenting symptoms, including persistent high fever, which is the hallmark of both, and then things like rash and red eyes, as well as swollen hands and feet can occur in both.
--:-- Dr. Kevin Friedman: COVID patients are presenting with much more heterogeneous and much more varied symptoms. Some have respiratory distress like adults with COVID. Others have decreased in the left ventricular pumping function of the heart. So the COVID patients are having much more varied presentation.
--:-- Sean Rameswaram: So just to be clear here, this syndrome is completely new, though it's similar to the thing called Kawasaki disease. This is something unlike you've ever seen?
--:-- Dr. Kevin Friedman: Yeah, we think it's an emerging new syndrome that has features of Kawasaki disease as well as toxic shock syndrome. It seems to be temporarily related to COVID.
--:-- Sean Rameswaram: So it seems to be a new emerging syndrome with features that include some of those seen in Kawasaki disease as well as other diseases. What are you calling this thing with your colleagues?
--:-- Dr. Kevin Friedman: So just in the last couple of weeks, people have come up with an acronym for it called PIMS or P-I-M-S for Pediatric Inflammatory Multisystem Syndrome. Okay. Anecdotally called it Kovasaki for combining Kawasaki and COVID. But I think that's one of the key things is we're still trying, we're still coming up with even a case definition to define what this disease is.
--:-- Sean Rameswaram: Can you help us understand how exactly we came to know that this was something different and when the first cases were documented?
--:-- Dr. Kevin Friedman: Yeah so about three weeks ago several groups in London made the world aware of this cluster of cases which seemed way out of proportion to the normal incidence of Kawasaki disease or these type of highly inflammatory conditions where children get very sick and are admitted to ICUs. They convened a webinar about two weeks ago where leaders from around the world in this field evaluated the data and all were in agreement that this seemed to represent a new syndrome that was certainly temporarily related with COVID with about half the patients being actually testing positive for COVID and then many having antibodies later on.
--:-- Sean Rameswaram: So it definitely seems to be COVID related. And we have heard anecdotal reports of cases throughout the US, but it seems to cluster in a couple areas, which are areas that have been heavily affected by COVID, primarily New York City in the New York metro area. They've also reported cases in Connecticut, New Jersey, as well as Detroit, Louisiana, and even in California. We've had a handful of cases here in Boston.
--:-- Sean Rameswaram: The second epidemiologic feature seems to be that it affects patients of Afro-Caribbean descent way more frequently than other ethnicities. And people are still trying to figure out what the ideology of that is. But from the London report, they said approximately two-thirds of the children or of Afro-Caribbean descent.
--:-- Dr. Kevin Friedman: Out of curiosity, were there any reported cases of this inflammatory syndrome from China?
--:-- Sean Rameswaram: Interestingly, no. And it's unclear if that was because it's a different ethnicity or a slightly different virus. There seems to be some evidence that the virus that we're seeing mostly in the East Coast of the U.S. is slightly different, came through Europe. And the virus that they're seeing saw in China and the West Coast is a little bit distinct.
--:-- Dr. Kevin Friedman: So no, there are really no cases reported of this inflammatory syndrome from China. It's unclear if that was because it wasn't recognized in the middle of an epidemic of adult disease that was vastly higher in numbers, or if it's a little bit different virus, or the same virus, but different effect in different patients of different ethnicity.
--:-- Sean Rameswaram: Do we know why this is only showing up in kids?
--:-- Dr. Kevin Friedman: Nobody knows. is they definitely have seen adults with some of the features, like very high levels of inflammatory markers and other lab abnormalities that we're seeing. I think in adults, the respiratory symptoms are so prominent and they're so severe that that's overwhelmed everything else. They are definitely seeing some of the features that we've seen in children, but not all of them. And I think the striking thing is that children are largely spared of their respiratory symptoms. And I think that's what's made the inflammatory component and then in some cases the cardiac component more prominent.
--:-- Sean Rameswaram: How lethal is it?
--:-- Dr. Kevin Friedman: Generally speaking, most kids recover. Some of them do get very, very sick and require ICU care for things like breathing tubes or medicines called inotropes to help their heart pump better or even for heart lung support. There have been a few reports of fatalities from New York City. They were recently reported just yesterday, I think, in the New York Times of three children who unfortunately didn't make it out of 100. But overall, it's still a very rare syndrome. And most children recover well with supportive care and the current anti-inflammatory therapies.
--:-- Sean Rameswaram: Do we know anything about how contagious this inflammatory syndrome is? Is it something that can spread from kid to kid? Or is it the COVID that's spreading from kid to kid and then this inflammatory syndrome appears?
--:-- Dr. Kevin Friedman: Yes, that's correct. inflammatory syndrome is not contagious at all. It seems to be the COVID exposure or COVID positivity that predisposes children to make an immune response likely to the coronavirus that then leads to this inflammatory syndrome. But the inflammatory syndrome itself is not contagious.
--:-- Sean Rameswaram: Have you encountered any children, any families who are dealing with this disease yourself?
--:-- Dr. Kevin Friedman: Yes, we've had about 10 children at Boston Children's Hospital with some variation of this inflammatory syndrome after COVID exposure. Approximately five of whom were very sick and required intensive care management. But no fatalities?
--:-- Sean Rameswaram: No.
--:-- Dr. Kevin Friedman: What do you tell parents who bring their kids in who are already terrified of COVID-19? I mean, maybe you've heard that their kids aren't at risk. And then now you have to tell them they have some inflammatory disease that, you know, doesn't even have a name yet.
--:-- Dr. Kevin Friedman: Yes I think the key things are that we still have to reassure families that this is incredibly rare and children are still seem largely spared This new syndrome certainly is a concern but it still extremely rare And we actually seen most children get better over about a week time. We would expect a full recovery, recognizing they may require a lot of intensive care management and can get sick in the interim.
--:-- Sean Rameswaram: How are the kids handling it that you've encountered, the 10 or so kids? Are they handling it okay?
--:-- Dr. Kevin Friedman: Yeah, children are really resilient. So I think they face things a lot better in most cases than adults, including their parents. And some of them are certainly are very sick and are in an ICU on a breathing machine or getting medicines to help their heart and may be sedated. But most children bounce back pretty quick and are able to adapt. And fortunately, especially with the cardiac involvement, in most cases, we've seen that get better with aggressive therapies.
--:-- Sean Rameswaram: More on kids and COVID with Dr. Friedman after a quick break. I'm Sean Rameswaram for him this is Today Explained.
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--:-- Sean Rameswaram: Dr. Friedman, I think when this virus hit the United States, we heard a lot about how kids will largely be spared. Is that still your understanding?
--:-- Dr. Kevin Friedman: Yes, to a certain extent. And certainly the data initially from China suggested that children were essentially completely spared with an incredibly low rate of children having even any kind of symptoms. With the emergence of this new inflammatory syndrome that's COVID related, it does make us think twice. And certainly we have to be a little bit more careful, particularly in children who are having prolonged fevers or otherwise acting very unwell. They need to seek medical attention. But I think it's important to be clear that this isn't children with low-grade fevers and mild cold symptoms. These patients are very, very sick with high persistent fevers. And then gastrointestinal symptoms have been very prominent.
--:-- Sean Rameswaram: Do we know anything more about why kids are still largely spared from COVID-19?
--:-- Dr. Kevin Friedman: Not exactly. No. Fortunately, most kids have few underlying health conditions. And certainly what we've seen in the adults who get very ill from COVID, it's largely the elderly and those with underlying medical conditions. But the exact details of why children seem to be largely spared, especially from the respiratory symptoms, still are not entirely clear.
--:-- Sean Rameswaram: So is that to say that the kids who are getting COVID-19 in the United States and elsewhere are largely ones who have underlying conditions?
--:-- Dr. Kevin Friedman: I think I would make a distinction that the initial data seems to indicate that children who get respiratory failure and require things like positive pressure ventilation or intubation with a ventilator, Those children seem to be largely children with underlying medical conditions that predispose them to that respiratory failure whereas the new inflammatory syndrome seems to be affecting all types of children without underlying predisposing medical conditions
--:-- Sean Rameswaram: Once a child has COVID does it look any different in a child than it does in an adult?
--:-- Dr. Kevin Friedman: Yes, I think the key differences are adults with COVID-19 are predominantly getting sick from respiratory failure and low oxygen levels, Whereas children, the respiratory symptoms are less prominent. And particularly those who develop this inflammatory syndrome often don't have respiratory symptoms or have minimal respiratory symptoms. And symptoms from the GI tract, including abdominal pain, vomiting, and diarrhea are much more prominent. And then a lot of them are actually presenting very sick with low blood pressure and hemodynamic shock where the blood pressure is low and they need support with medicines to help their blood pressure.
--:-- Sean Rameswaram: If children do get COVID-19, what are their recovery rates right now? Do we know?
--:-- Dr. Kevin Friedman: Generally speaking, most children who are getting COVID-19 are still highly likely to be minimally symptomatic or asymptomatic. So I'd say the overall rate of full recovery is extremely high. And those presenting with the respiratory type of symptoms, it largely depends on their underlying medical conditions. But for children who have minimal underlying medical conditions, also the recovery rate is very high. The last type of presentation is with this highly inflammatory syndrome. With that, we're still learning a lot, but it seems that the majority of children still recover fully, although there have been a few concerning cases where children have not recovered that have been recently reported. And those children seem to have had severe involvement of their heart and true heart failure related to this syndrome.
--:-- Sean Rameswaram: So I guess with super high recovery rates and even low rates of infection and most kids being asymptomatic, I imagine a lot of people are wondering why their kids can't go back to their normal lives. What would you say to those people who are wondering about that?
--:-- Dr. Kevin Friedman: I think there's two components to that. The first is from a global epidemiologic standpoint, the vast majority of children show no symptoms of either respiratory illness or this new inflammatory condition. They can still carry the virus and spread it to others and from a global standpoint the only way to stop spread is social distancing until we have a vaccine so probably most importantly is that they can be carriers of the virus even if they're asymptomatic and then second we're still learning a lot about this inflammatory syndrome and some children are getting very very sick with a very small number who've not survived and certainly we don't we don't want to expose more children to the risk of developing this inflammatory syndrome or respiratory failure related to COVID-19.
--:-- Sean Rameswaram: So what advice would you give parents who are trying to maintain their sanity while keeping their kids at home in this moment?
--:-- Dr. Kevin Friedman: I think the key thing to recognize is this is still extraordinarily rare. Even with the new data that's emerged, children are still much safer in this outbreak than adults, particularly adults who are either elderly or have underlying medical problems. And the vast majority of children who get infected still have minimal or no symptoms. And even in the worst case among the children who are getting this new inflammatory syndrome, we do have treatments that are both supportive and help to decrease the inflammation. So I think if a child's having high persistent fevers with GI symptoms and otherwise acting very unwell, then they need to seek medical attention. But overall, it's still a very rare syndrome. And most children recover well with supportive care and the current anti-inflammatory therapies.
--:-- Sean Rameswaram: Dr. Friedman, thank you so much for your time.
--:-- Dr. Kevin Friedman: Thank you very much. I appreciate your time.
