India needs specialised healthcare to treat Covid-19 in children: Experts

Country must prepare though there is no science or data to back fears that children will be hit in the next wave of infections.

The medical expertise, equipment and approach needed to treat children with Covid-19 is unique and this is a challenge in India where the health infrastructure has been hit by decades of underfunding and neglect, say experts. Vaccination against the virus too is necessary for children but a host of complex issues need to be resolved first, they say.

The Centre and state governments are increasingly stressing on preparedness to deal with paediatric Covid care: Prime Minister Narendra Modi, in a meeting with local government officials on May 20, 2021, urged them to collect data on how Covid-19 is affecting children. Maharashtra has set up a state task force focussed on the infection among children and Delhi government is planning one as well.

So far, there is no science nor are there data to back widespread fears that children will be hit more severely in the anticipated third wave of the pandemic. Infections among children have been mild, and even severe cases among them tend to be treatable, IndiaSpend reported on May 23, 2021. It is also likely that the number of cases among children in the second surge is linked to the sheer number of cases in a short span, said doctors.

What can be done to make paediatric care for Covid-19 more efficient? Experts from the fields of paediatrics and immunology pointed out that children are vulnerable to Covid-19 in unique ways and need special and different attention when they are infected. This means child-friendly care facilities, infrastructure and treatment approaches, as we explain later.

Experts also believe that with about 40% of India's population aged under 19, children have to be seriously considered for Covid-19 vaccination. The Indian government has announced that Bharat Biotech, the company manufacturing the Covaxin vaccine, will be beginning phase 2 and phase 3 clinical trials among children aged 2-18 years in the next two weeks. In the United States of America and Canada, the Pfizer-BioNTech vaccine has been approved for children aged 12 to 15. This vaccine is not approved in India for children or adults.

While Covid is milder in children, the treatment options for them are also fewer: The government issued and updated its clinical management protocol for adults with Covid-19 on May 19, 2021. On April 29, 2021, it issued a protocol for children. Many of the Covid-19 drugs tested for efficacy in adults have not been tested enough for their use in children. For example, the paediatric protocol notes that there are "limited data'' on the use of drugs such as remdesivir on children.

Focus on children: Courts, governments

Over the last month, there has been increased focus on ways in which the pandemic is affecting children. Early in May, Justice S. Ravindra Bhat took cognisance of the vulnerability of children at a meeting of the Supreme Court's Juvenile Justice Committee with United Nations Children's Emergency Fund (UNICEF). The committee discussed issues such as children being orphaned when both parents die of Covid-19 or not having access to healthcare and supervision when their parents are hospitalised with the disease. Justice Bhat also sought that parents of young children or those who work with children be vaccinated on priority basis.

Also at a hearing in the Supreme Court this month, Justice D.Y. Chandrachud said that the central government needs to prepare for the third wave of Covid-19 and keep a special focus on the needs of children, including vaccinating them.

The Maharashtra government set up a paediatric task force for Covid-19 and is looking to set up more specialised units for the treatment of sick and newborn infants, install ventilators better suited for children and draft a treatment protocol for the young. The task force has submitted its report to the state government.

To gear up paediatricians for any Covid-19 challenges, and also to calm the anxieties of parents and school administrations, the Maharashtra government and the Indian Academy of Paediatrics will be developing special guidelines, Samir Dalwai, a paediatrician and a member of the task force, told IndiaSpend.

"We have been organising training and orientation sessions online for thousands of paediatricians around the country. Even the chief minister, Uddhav Thackeray, has attended some of these, to give the message that this is serious and that the government as well as the medical community should take it seriously," said Dalwai.

The paediatric task force set up by the state government will be looking into finalising guidelines for the clinical management of children, training paediatricians and analysing the existing infrastructure for treating kids and what may be needed, said Dalwai.

In Delhi too, the state government has decided to set up a special task force to focus on Covid among children and the government-run Lok Nayak Jai Prakash hospital has added six paediatric ventilators to the existing 15, as per a May 21, 2021 report in The Times Of India.

'Nothing to show children at greater risk'

Up to 80-90% of children who are infected with SARS-CoV-2 will be asymptomatic, and only about 1-3% of those who are symptomatic will need intensive care treatment, according to the Indian government's clinical protocol for management of Covid-19 in children. These numbers are far smaller than those seen adults, according to the Indian Academy of Paediatrics.

Some of the fears about the susceptibility of children to SARS-CoV-2 stems from the discovery of the newly identified variant, B.1.1.7. But these fears may be premature, shows existing evidence. A February 2021 paper in The Lancet analysing this variant's effects said that while more children had been admitted to hospitals in the United Kingdom between November 2020 and January 2021 compared to March 2020 and May 2020, this could be due to a higher overall caseload. It said that there was "no evidence of more severe disease having occurred in children and young people".

A lot more research needs to be done on this variant but investigations so far do not indicate that children are particularly vulnerable to it, said Maria Van Kerkhove, an official at the World Health Organization (WHO).

But public comments--that children may be more affected in future waves of Covid-19--have stoked anxiety. For instance, Delhi chief minister Arvind Kejriwal tweeted this week that India's third wave would be very dangerous for children.

While some medical experts warn of rising Covid cases among children, others say there is no evidence to establish this. "The current evidence indicates that severe illness in infected children remains much less common than among the elderly this year, just as it was last year. I do not think there is any evidence so far that children are being affected more or worse this year," said Satyajit Rath, immunologist and former scientist at the National Institute of Immunology, New Delhi.

There are questions too about the warnings about the third wave and its impact on children. "People have been making very loose comments about a third wave affecting children more. There is no epidemiological basis for this so far, and it is just conjecture," said Tanu Singhal, a paediatrician and infectious disease specialist at the Kokilaben Ambani Hospital in Mumbai. "Yes, there might be a third wave. And by that time, a wide section of the adult population may be vaccinated. Hence it may seem like more children are being affected, but this may only be in relation to people affected in the third wave, and not an overall indication that children are at a greater risk."

Shortage of paediatricians, ICUs for children

Experts pointed out to IndiaSpend that all health infrastructure in India needs to be ramped up given the system's chronic under-funding and neglect. However, the medical expertise needed to treat children as well as the equipment in intensive care units (ICUs) need to be different for children, they added.

"The equipment for children in hospitals has to be paediatric-friendly. The sizes are very different for children--an adult may come in an average size range, but as paediatricians we may be treating a newborn infant weighing just 600 gm, or a child weighing up to 100 kg," said Jesal Sheth, paediatrician at Fortis Hospital, Mulund. For example, someone trained in dealing only with adults will find it hard to intubate a child, she said. "Furthermore, children may also be non-verbal and won't be able to describe their illness. So only a trained paediatrician can recognise from non-verbal communication, what the child may need."

So far, the health infrastructure for children has not been overwhelmed in either the first or second wave, said Sheth. But the country will have to keep preparing for any future situation where this could happen, she said.

"Paediatric ICUs would be useful, especially because severe COVID-19 in children can take somewhat special different forms than in adults," said Rath. There is already a "sad and glaring lack of public health facilities in India, both for adults and children. So this will also become a major problem in effective treatment of the children who will become severely affected", he said.

There is an 82% shortage of paediatricians in India's primary health centres, according to a parliamentary standing committee report in 2015. Up to 62.8% of positions for paediatricians in community health centres were vacant, according to the same report. This shortage fits into a larger context of an overall shortage of doctors in India--while the WHO's recommendation is a doctor-population ratio of 1:1,000, India reports 1:1,674.

There should be emergency-rehearsals for crisis management, said Sheth, where work-flows can be set and practised to deal with any emergency in the future. "These rehearsals should look into issues like, what do health workers need to do when a child is brought to a hospital for Covid-19 treatment, what preliminary treatment can be started, how to monitor them and when to refer them to further treatment," she explained.

'Long path' to vaccinations for children

Up to 40% of India's population is aged under 19 years, according to the 2011 census. This is projected to fall to 34.6% by 2021. Currently the government's COVID-19 vaccination drive is limited to those over 18 years of age. This implies that about half the country is eligible and trying to get vaccinated, and another half is not yet old enough for immunisation.

"Yes I would recommend vaccination for children at the earliest, once its safety profile is established. About 40% of India is aged under 18 and we cannot leave them unvaccinated," said Dalwai, adding that vaccinations of children will need to happen at some point so that schools can be safely re-opened.

Rath welcomed the announcement of clinical trials of Covaxin for children. "We should definitely start trials for children and should have started it earlier. Given the evidence that has already come in all over the world on adult Covid-19 vaccination, starting formal trials in children is safe and the right thing to do," he said. However, the path ahead will not be short--trials have to be completed, regulatory approval has to be given and the overall vaccine shortage has to be addressed, he said.