The COVID situation in Austin, Texas, is worrying. Like the rest of Texas, the area around Austin is experiencing an unusually bad surge that is straining local resources: in the 2.3 million-person region, there were only two ICU beds remaining on Tuesday. And like the rest of Texas, Austin has been unable to mandate masks without violating an order from the governor. There’s also been a shift in who is getting sick. As the more contagious delta variant spreads and as more adults are protected by vaccines, patients are skewing younger. Since July, more than 780 children have been admitted to Texas hospitals with COVID, and since the start of August, 40 children on average have been hospitalized each day. With the start of school just days away in Austin and the virus tearing through the school-aged population, parents are trying to figure out how to shift the way they think about their children’s risk.
The good news is that children have little risk of dying from COVID. And even in Austin, where doctors have reported seeing an influx of children in hospitals in the region, pediatricians have a surprisingly reassuring message: Your kid is going to be OK.
Children represent around 14 percent of COVID cases nationwide, but fewer than 0.03 percent of those cases resulted in death, according to the American Academy of Pediatrics. Children can spread the virus, and infants and children with underlying medical conditions or weakened immune systems are considered at higher risk, but overall, very few will experience anything worse than a fever and cough if they contract the virus, even with the delta variant. “Almost always it’s mild and transient and it goes away and they’re back to normal,” said Dr. Don Murphey, an Austin pediatric infectious disease specialist who chairs the Texas Medical Association’s science and public health council.
Still, doctors said they understood why parents were anxious. Murphey has personally seen an influx of pediatric cases in children’s hospitals across Texas over the past couple weeks. The severe cases have been worse than in the early pandemic, too. “Kids are getting sicker than we’d seen in the past,” said Dr. Lauren Gambill, a professor of pediatrics at the Dell Medical School at UT Austin.
For the most part, the pediatricians said, the children they see with severe cases are unvaccinated teenagers, many of whom seemed to have been healthy otherwise. Murphey said it’s not clear if teenagers are more vulnerable or if teenagers are simply more likely to catch COVID because of activities and behavior. (He advises parents to treat children of all ages—at least those with the same vaccination status—as if they’re at equal risk.) Once again, there’s good news: children 12 and older are eligible to receive the COVID-19 vaccine. As of now, 36 percent of 16- and 17-year-olds and 24 percent of 12- to 15-year-olds are vaccinated nationwide, according to the AAP.
The teenagers aren’t the only ones being hospitalized in greater numbers, though. Central Texas is also experiencing a severe outbreak of RSV, a common respiratory virus that can be dangerous for infants. It is highly unusual to see RSV outside of the winter, and experts believe the outbreak is simply the delayed onset of the standard winter outbreak, which children avoided by staying home and wearing masks: “They lost a year of their normal viral illnesses building up immunity,” Murphey said. “Now they’re catching up.” Some of the physicians estimated that there were about as many pediatric hospitalizations from RSV as there were from COVID, and some have seen cases of children infected with both. It doesn’t appear that COVID puts RSV patients at higher risk or vice versa.
The case numbers in Austin are worse than they were early in the pandemic, but even there, the pediatricians aren’t advising parents to act like it’s the spring of 2020 all over again. There are several major differences. Vaccines protect the adults who live with the children from getting more severe cases. Authorities have now established the efficacy of distancing, mask-wearing, and proper ventilation, all of which have been shown to make school settings safer. And schools taking full precautions can have a very low rate of transmission. “It’s important to remember that we have a lot more information than we had 18 months ago,” Gambill said. And most pediatricians agreed that the hardships of remote learning and social isolation could no longer be ignored. Dr. James Anderson, a pediatrician at Austin Regional Clinic Far West who works primarily with pediatric mental health, says he prioritizes mental health because of the increase he’s seen of depression and anxiety. “To me, kids are lower risk, and I have to balance what is their mental health, versus the risk of COVID,” he said. “The COVID impact isn’t just sickness.”
Experts agree that as long as the current delta-driven surge lasts, kids should keep indoor gatherings to small numbers and their social activities outside as much as possible. “In May, could your kid have done indoor gymnastics or dance class?” said Dr. Ari Brown, the CEO of 411 Pediatrics in Austin. “Sure, because case counts were low. But now, indoor activities where you have close contact with kids who aren’t vaccinated? That’s a riskier proposition.”
Most also agreed schools should require students to wear masks. (On Monday, Austin ISD announced that it will mandate face masks, in defiance of Gov. Greg Abbott’s executive orders banning such mandates.) “Sometimes we worry kids won’t be able to wear them, but kids are pretty amazing,” Gambill said. Gambill said her 3-year-old daughter wears a mask to school every day and has no issues keeping it on. “They’re capable of rising to challenges,” she said. The pediatricians were universal in saying that given the virus’ lower risk to children, they would personally send any children aged 3 or older to in-person classes, given the usefulness of socialization starting at that age.
“I really do try to reassure families that most of the kids who get COVID are going to be fine,” Brown said. “It’s just—it’s not a zero risk choice. But your child needs to go to school. You can try to mitigate risk as much as you can by masking, not letting them stick their hands in their mouth, but at a certain point you’re choosing—you know there’s a decent chance they’ll be exposed.”
Still, each pediatrician we spoke with also stressed that every risk calculation was a personal one and that there was no single correct decision. If there’s a medically vulnerable adult in the child’s household, that changes the calculation. As does the parent’s anxiety. “The kids pick up on it,” Anderson said. He said that while he strongly recommended that young children go to daycare and older children attend in-person classes and regular social activities with other kids, some families will find that any given activity is not worth the stress. “If the parents aren’t comfortable, I would probably not recommend it.”
And because of the unresolved questions about long COVID among teenagers, some parents might be more conservative. According to Gambill, the conversations about risk in the world of pediatric medicine haven’t been able to move beyond hospitalization and death because there isn’t enough information about long COVID and children to know how to factor it in. Murphey said that he suspects Texas will begin to see more chronic fatigue cases for children, but he hasn’t seen much of it yet. Without much information, the pediatricians said, and given the rarity of the anecdotal cases, parents should continue to think about risk in terms of active illness.
More importantly, they advised parents not to hunker down and wait for a return to normalcy as they thought about risk. Murphey pointed out that some guidelines for when parents should ease back on restrictions rely on potentially unattainable goals. “They’re low rates, and we’ve almost never been that low, except in the spring,” he said. “If you look at recommended rates, it’s hard to say, ‘we’re going to wait to get that low.’”
Anderson also advised against putting hopes for “normalcy” on an unknown future improvement in the pandemic. “The fatalism from keeping pushing it back is hard on the kids,” he said. “We need to normalize their life as much as possible, within the comfort level of their parents.”
There is room for parents to hope beyond the rise and fall of case numbers, though: Health experts believe that a vaccine for children younger than 12 is just a few months away. At that point, the pediatricians said, they would breathe a lot easier.