Why have so few children been infected with COVID-19? Do children have to wear masks? When should kindergartens open? We posed these and other questions to  Prof. Dr. Ute Spiekerkötter, the Medical Director of the Center for Pediatrics at Medical Center – University of Freiburg.

There have been media reports that children can be easily infected with the corona virus but their symptoms stay relatively mild. What have you observed so far in Freiburg?

In general, we have only had very few children with COVID-19 in our hospital. In fact, only one child had to be treated in the intensive care unit. We didn’t detect much of Sars-Cov2, although we tested all children with clinical symptoms such as fever, breathing problems and upset stomach who needed to be admitted to hospital. The majority of the tested children presented these symptoms due to other infections.

There is currently a lively discussion between scientists whether children and adults get infected similarly. A few recently published clinical studies describe that children are infected more seldom and tend to only present mild symptoms (P. Zimmermann and N. Curtis: Coronavirus infections in children including COVID-19, The Pediatric infectious disease journal 2020).

In Germany, children and adolescents up to 14 years of age make up just 3% of all registered corona cases in the country, despite making up 13% of the national population (Robert –Koch Institute data). The final reasons for the lower incidence of COVID-19 cases in children are still unclear, but there are a few hypotheses: 1. Children often and regularly have to fight infections and their immune system is used to constantly battling viruses, also corona viruses. 2. The upper respiratory tract epithelial cells carry less ACEII receptors which are important receptors for the import of the corona virus into the cells ( A.B. Patel and A. Verma: Nasal ACE2 Levels and COVID-19 in Children, JAMA.  2020. doi:10.1001/jama.2020.8946).

What symptoms do children with COVID-19 have according to your experience? How long do children stay sick and contagious? Which children are in the higher risk group?

Children usually have respiratory symptoms. In many cases the symptoms are so mild that no inpatient care is necessary. These children are requested to follow home quarantine provisions for 14 days until the child is completely healthy and presents no symptoms.

It is still not clear which children are more prone to these infection. Up until now a predisposition to COVID-19 was neither found among children with immunosuppression or oncological diseases nor among children with any other chronical disease including chronical lung disease.

Should children disinfect their hands? Should children wear masks?

When children are in a hospital, they should disinfect their hands. In every day life we recommend regularly washing hands with soap.  In Baden-Württemberg, children older than 6 years of age have to wear masks  in shops and public transportation.  In our hospital all patients older than 6 years must wear masks.

According to the study published in the American journal „Clinical Infectious Diseases“, children do not play any significant role in spreading the virus. Freiburg is currently working on a similar study. Could you please tell us about the first results?

Not yet published results in Freiburg show that currently only a very small number of children had contact with SARS CoV2.

We examined 500 parent-child pairs (n=1000) and only one pair showed a positive PCR test for SARs-CoV2 that also correlated with a past clinical infection. The same investigation has taken place at three other University hospitals in Baden Württemberg, with together another 3000 participants. All of those had negative PCR tests for SARs-CoV2. These findings do currently not allow to make final conclusions about the role children may play in the spreading of the virus; but they do allow to conclude that the infection rate in the general population is much lower than expected.

Spain, UK, France and Switzerland report a puzzling connection between Coronavirus and Kawasaki syndrome in children. Are there any similar cases in Germany and how dangerous is this syndrome?

There have indeed been a few individual cases of this rare form of COVID-19 manifestation in Germany, also in Freiburg.  It is an obscure form of vasculitis similar to Kawasaki syndrome. However, in spite of severe symptoms, our little patient in Freiburg has overcome the critical  state.

What is your opinion on re-opening kindergartens, schools and playgrounds?

The German Society of Pediatrics and Adolescence Medicine (DGKJ) stated: “All current measures undertaken by government have very strong effects on children’s and adolescents’ lives. Shutting down kindergartens, playgrounds, schools and sport facilities have significantly limited vital conditions for healthy physical, psychological and social development. Introduction of Home-Offices satisfies the needs of employers and parents but not children. There is not enough support to ensure the necessary care for children. The gradual  re-opening of kindergartens must be based, first of all, on the needs of children and not parents and employers. Exceptional attention should be paid to children in difficult life situations (single parenting, parents with psychological disorders or addictions, vulnerable families). Long pauses in children’s care should be reduced.”

DGKJ also refers to the report published by The German National Academy of Sciences Leopoldina about corona pandemics, in which it is  strongly recommended to re-open schools for all children and adolescents as soon as possible (introducing new hygiene measures and possibly alternative education models).

We – pediatricians – agree that the quarantine exit strategy must put the needs of children and adolescents at the forefront.

• Center for Pediatrics