NOW THAT Aubrey Samost and her husband are vaccinated against COVID-19, Samost said the Cambridge couple wouldn’t think twice about going out to dinner – except they have a 15-month-old daughter, who is too young to be vaccinated.
“It’s been tough figuring out what we can and can’t do with her,” Samost said. “We feel like we can do a lot and she can’t.”
The couple sends their daughter to daycare, and has started socializing with other families where the adults are vaccinated, but they will not take her inside stores. Samost is an anesthesiologist and her husband is a scientist, yet she acknowledges that their COVID-related parenting decisions are made as much on gut instinct as on data.
“We know her risks if she gets COVID are low,” Samost said. “But we’d also feel really guilty if anything happened to her, so we still tend to err on the side of caution.”
For many in Massachusetts, life is slowly returning to normal. Government has dropped almost all COVID-related restrictions, allowing businesses to fully resume operations. More than half the state’s population is fully vaccinated and two-thirds have gotten one vaccine dose. But children under 12 remain ineligible for the vaccines, putting parents in a quandary as they must make difficult personal decisions about how much risk they are willing to take.
“It’s definitely a difficult question and the conversation is very confusing,” said Lloyd Fisher, president of the Massachusetts chapter of the American Academy of Pediatrics. While the US Centers for Disease Control and other organizations are making recommendations for vaccinated and unvaccinated adults, Fisher said, “Nobody’s giving clear guidance for children.”
It is clear that children are at less risk than adults from COVID-19, a virus that has been most dangerous for the elderly.
Vandana Madhavan, a pediatric infectious disease specialist at Massachusetts General Hospital, said children are less likely to get COVID-19 and less likely to transmit it. The virus generally causes only mild symptoms in children, and many children admitted to the hospital with COVID-19 were actually admitted for other reasons but happened to also have the virus.
However, there have been cases of children coming down with multisystem inflammatory syndrome after having COVID-19, a serious condition where body parts can become inflamed, such as the heart, kidneys, or other organs. Madhavan said the risk is rare, but not zero.
Rick Malley, an infectious disease physician at Boston Children’s Hospital, said the best way to think about the question is in terms of relative risk. “If someone asked the question could COVID ever make a child sick the answer is of course yes,” Malley said. “But when you talk about it relative to the risk that this virus poses to older patients or individuals who are immunocompromised, in the case of children, the risk of severe disease from COVID-19 is dramatically reduced compared to that of adults.”
One significant question then becomes how likely children are to contract the virus – which depends in large part on how prevalent COVID-19 is in the child’s community.
Shira Doron, an infectious disease physician and hospital epidemiologist at Tufts Medical Center, said it is a misconception that unvaccinated equals unsafe. “Our kids were unvaccinated in 2018 and they were safe,” Doron said. “Just because you’re unvaccinated for something doesn’t mean you’re at high risk for it. It has to be a combination of your susceptibility and vulnerability and the chance of encountering infection in the community.”
Doron said there is no magic vaccination number at which a community can be considered “safe,” but generally, low case rates make everyone safer. She said case rates in Massachusetts, which have been plummeting, are already at a point where any individual child’s risk of getting COVID-19 and having a bad outcome is probably similar to the chance of having a bad outcome from the flu during a regular flu season. “We are probably already at a point where the risk of being in a car accident on the way to school is higher than the risk of acquiring COVID at school and having a bad outcome,” Doron said.
Doron said families and communities need to think about the risks and benefits of imposing restrictions on children. Several experts have blamed COVID-related precautions – like school shutdowns and isolation from peers – for leading to a pediatric mental health crisis.
Doron questioned the perception that requiring children to wear masks has no downside. She said there is a benefit to encouraging children to exercise outdoors, even in the heat, which is harder with a mask. Children who are hearing impaired or have trouble with social development may need to see facial expressions to communicate. Requiring universal masking also makes it harder to differentiate between high and low-risk situations, so it might make more sense to save masking for the times and locations when it is more necessary – indoors or when case numbers are high.
Doron said she hears frequently from parents who still “have a ton of fear” around COVID. But, she said, “We don’t want fear-based decision making. We want science-based decision making.”
Fisher advises families to think about their individual situation. If the adults in a family are vaccinated, having a child unmasked outdoors poses very low risk to anyone. Gathering indoors with another family when all the adults are vaccinated is also low-risk. But if a family member is immunocompromised, has a chronic illness, or is unvaccinated, that increases the risk of various activities.
“It’s not a clear-cut answer,” Fisher said. “We know the risk is low, but the risk is still not zero.”
Fisher said he is encouraging families to use the summer to get outdoors, where the risk of virus transmission is lowest, and let children go to camp and play in parks. “Even though children have not on the whole been the ones who have gotten severe disease, they are suffering by the lack of in-person schooling, the lack of ability to socialize,” Fisher said.
Madhavan said she advises families to think about where activities are occurring and with whom. Playing in a park is safer than eating in a restaurant. Walking along a street is safer than attending a crowded concert. Visiting with one family where the adults are vaccinated is safer than going into a public indoor space, where the vaccination status of others is unknown. The risk to immunocompromised children is greater than the risk to healthy children.
“It’s not saying great, return to normal, but really thinking about what activities would both benefit your mental health and allow you to feel you’re getting towards normal while still being mindful of the still-present risk,” Madhavan said.
One question is whether newly emerging COVID variants are more likely to harm children that the initial virus. So far, Malley said, the variants have shown to be more easily transmittable to both adults and children. But there is no strain that is causing more virulent disease in children.
Data showing that a higher proportion of cases are occurring in children does not necessarily reflect an increase in childhood illnesses but a decrease in adult cases as more adults are vaccinated. And Doron said studies have found that the three COVID vaccines approved in the US are effective against the existing variants.
At a societal level, the more people who are vaccinated, the less chance COVID-19 has to spread. But Malley noted that some countries have had extraordinary success crushing the virus even without vaccinating children. Israel is the most frequently cited example of a country with high rates of adult vaccinations and extraordinarily low case counts, even though schools are open and children under 12 are unvaccinated. The United Kingdom also has low spread of COVID, likely due to its strategy of spacing out first and second vaccine doses by 12 weeks, allowing more people to get their first doses earlier.
“You could envision a scenario that by the time the vaccine becomes available for very young children, there’s so little disease going around that the bang for the buck is really very small,” Malley said.
Rebecca, a Cambridge scientist who declined to give her last name, said she is waiting for either case counts to dramatically decrease or for her two and six-year-old children to be vaccinated to stop restricting their behavior. For now, she is not letting her children travel on planes or do any indoor activities, even though she and her husband are vaccinated. Rebecca, interviewed on a playground, said her priority is keeping her kids healthy and able to attend daycare and school.
“We’ve gotten used to it over the past 15 months so it’s pretty easy to keep it up, especially now that the weather’s nice,” she said.