Jaipur: It took four-five days for 13-year-old Shrihaan Tandon's COVID-19 induced fever, which had spiked to 102 degrees, to break. Then, on the ninth day, just when Shrihaan felt he was recovering, he developed mild conjunctivitis in his left eye, he told IndiaSpend over a Zoom call from Gurugram, Haryana on April 28. He also had a sore throat and a cold. When Shrihaan first developed COVID-19 symptoms, he thought "Now that it has happened, it has happened, what can I do? I have to deal with it," he said.

Shrihaan had a moderate case of COVID-19, and most children get a mild infection, doctors and families told us. Shrihaan's younger sister, eight-year-old Nandika, who was the first in their family of five to test positive, had mild fever for almost nine days, that on some days would touch 100 degrees, said her mother, Puneeta Tandon. "It wasn't good, it wasn't bad, it was normal," Nandika cheerfully told IndiaSpend.

In the seven months from the start of the pandemic in India in February 2020 to August 2020, the Bai Jerbai Wadia Hospital for Children in Mumbai had seen 150 cases of COVID-19, or 21 cases a month, on average. This year, in just two months, the hospital has seen 90 cases, its CEO Minnie Bodhanwala told IndiaSpend.

Paediatric pulmonologist Indu Khosla at Mumbai's SRCC Children's Hospital diagnoses around 15-20 children with COVID-19 every day, these days. In the last wave in 2020, "children were hardly contracting the disease; the caseload was 10-15% of what it is today", she told IndiaSpend. The youngest patient she has treated was four months old.

Nearly 11.5% of the 5.6 million COVID-19 cases reported between January 1 and April 21, 2021 were in the age group zero to 20 years, government data show. This is just under the 12% of cases in this age group in all of 2020, but doctors say they are treating more children and adolescents with COVID-19 in this second wave because of the sheer number of cases in a shorter span of time. Nearly 42% of all confirmed COVID-19 cases during 14 months of the ongoing pandemic in India, were recorded in the two months between March 1 and April 30, 2021. Also, this time around certain variants of the disease are more infectious, affecting almost all members of a household, doctors say. But among children, there are few serious cases, and even these are mostly treatable, they tell us. On May 2, India had 3.3 million active COVID-19 cases.

COVID-19 symptoms presenting in children

Most children with COVID-19 have gastroenteral symptoms such as vomiting and diarrhoea, and mild fever, cough and cold, doctors said. They do not require any treatment other than paracetamol and multivitamins. Many children are also asymptomatic and tested only because a family member has COVID-19, said Bodhanwala.

There are few cases in which COVID-19 impacts children's lungs, leading to pneumonia and the child requiring oxygen or, in more serious cases, a ventilator. Severe COVID-19 usually occurs in children above 13 years, and mostly in those with comorbidities. "But very few children have comorbidities in the first place," so severe COVID-19 cases are usually seen in a very low proportion of children, said Khosla.

Even SRCC, which is a tertiary care and referral centre, has seen few severe COVID-19 cases in children, and all her patients admitted with severe COVID-19 have recovered until now, said Khosla. Even in a serious case in which a patient had COVID-19 induced encephalopathy, which means that the disease had impacted the brain and the patient was unconscious, "the child has now recovered", she said.

Doctors use steroids such as prednisone and dexamethasone to treat severe COVID-19 cases in children, said Khosla. Doctors might use low molecular weight heparin, an anticoagulant, based on a D-dimer test, which can help detect blood clots. In cases where the lungs have been impacted badly, the doctor might prescribe the antiviral remdesivir, which has been approved for children weighing above 3.5 kg, but only in rare situations, she added. Bodhanwala concurred, saying remdesivir is rarely needed for child patients.

If a child develops a fever or any other COVID-19 symptom, doctors ask that parents first consult them over the phone or on video [call] and avoid rushing to the hospital. "50-60% of patients don't require anything but video consults," said Khosla. If high fever persists beyond day five, however, parents should ask the doctor if any medical investigations are required.

Parents who notice symptoms such as unusual skin rashes, persistent fever, oxygen at 94%, difficulty breathing, drowsiness and decreased appetite in children diagnosed with COVID-19, however, should immediately consult a doctor, Bodhanwala recommends. In this second wave, Wadia hospital has seen many cases of children with both COVID-19 and typhoid, so both diseases need to be treated simultaneously, she adds.

Kawasaki-like symptoms treatable in most cases

One of the more serious effects of COVID-19 on children, which doctors had started seeing early in the pandemic, occurs some days after a child has recovered from COVID-19. Called Multisystem Inflammatory Syndrome in Children (MIS-C) or Pediatric Multisystem Inflammatory Syndrome (PIMS), it results in inflamed blood vessels throughout the body which "can limit blood flow, damaging the heart, kidneys and other organs", according to John Hopkins Medicine. Sometimes referred to as Kawasaki disease-like symptoms due to similar symptoms of fever, inflammation and rash seen in that disease which generally affects children below five years, MIS-C or PIMS is rare and also treatable in most cases, doctors told us.

In the ongoing second wave, Wadia hospital so far has seen fewer cases of this syndrome than in the first wave, when it had treated 21 children for PIMS. But this might change in May as PIMS is an immune reaction of the body after the child has recovered from COVID-19, Bodhanwala said.

Being alert for MIS-C or PIMS symptoms

Although most children recover from MIS-C or PIMS, it must be treated by a doctor and late discovery can be scary for parents, as Khushnooma Kapadia in Mumbai learned. Her 11-year-old son Nivaan was diagnosed with MIS-C and had a harrowing experience, she told IndiaSpend.

It started off with Nivaan feeling uneasy one night, which turned into high fever by the next morning. Eight days earlier, the Kapadias' 16-year-old daughter had tested positive for COVID-19 and was in isolation. They thought that Nivaan too had COVID-19, even though he had tested negative earlier, and would soon recover just like his sister, said Kapadia. Nivaan's fever raged for four days, and on the fifth day, he woke up with a large swelling on his neck, diarrhoea and vomiting. He also had a skin rash that developed over the next two days. "Nivaan was devoid of energy, almost like he was doped. I had to help him brush his teeth and bathe. We would force-feed him whatever we could, like juice. At one point I thought we might have to use a diaper because he had uncontrollable diarrhoea," she said.

Nivaan was tested again for COVID-19, and again the test was negative, which baffled his parents. But his Immunoglobulin G (IgG) report, which tests levels of common antibodies in the body, was 20 times the norm, which meant he had had an asymptomatic COVID-19 infection even before his sister, which had resulted in MIS-C. "We were shocked… The doctor told us if we did not immediately admit him to the hospital, it could be fatal. That was when we broke [down]," Kapadia said.

Nivaan was admitted in SRCC Children's Hospital in Mumbai for five days and treated with steroids, immunoglobulin and anticoagulants. His father, who is a doctor, accompanied him at all times, and the doctors and nursing staff were excellent, his mother said. "One day at the hospital, they had to try five times with the needle to find his vein. That day when I video-called him, he turned his face away. He was trying to be brave but he knew if he spoke to me he would break down."

Kapadia pointed out that her family have the best care possible as her husband is a physician, but were not looking out for the signs for MIS-C. She asked parents to be "vigilant but not paranoid". "We were overjoyed when Nivaan came back home. We just held each other because we had escaped something very serious," she said.

Importance of a stress-free atmosphere to help children recover

"As parents, it is extremely tough to see your children going through this," said Puneeta Tandon. "The only advice I want to give parents if their spouse or children are positive for COVID-19, is not to get anxious or too stressed," said Tandon.

All members of the Tandon household had COVID-19-like symptoms, even though Puneeta had tested negative and her mother-in-law's report never reached them. Her husband, Akash, 45, had an acute case of COVID-19 with pneumonia and difficulty breathing, but Puneeta was able to care for him at home, as she herself had very mild symptoms. "There were times I would break down alone in the bathroom," she said, but did not let the children see her distress, emphasising that it is important to keep children calm and stress-free to help their recovery.

Previous experience with COVID-19 in the family helps. Aarti (who wants to use only her first name in this story) and her two children had contracted COVID-19 in March 2021. "My husband had got COVID-19 earlier in February and at that time we had been anxious, but by the time the children got it, we could manage it well," Aarti told IndiaSpend over the phone from Mumbai. It also helped that her children could be isolated with her, she said.

Doctors recommend keeping infants and very young children with their positive parent/s, even if the children have tested negative. This is because it is very likely that the child has caught the disease and asking others, especially elder persons like grandparents, to take care of the child can be dangerous. "Children usually have mild infections but it could be more dangerous for the elderly," Khosla said.

That is exactly what 39-year-old Puja Parekh did when she, her husband and their daughter, Vedika, 9, tested positive for COVID-19. "We did not want our 1.5-year-old son to go through the testing but we assumed he was positive as we had been hugging and kissing him every day before we realised we had COVID-19," she said.

Only if the parents are very ill and unable to take care of the child should they be separated, Khosla said. It is tough on parents if they too have severe COVID-19 along with the child, Bodhanwala said.

The separation has forced some children to grow up quickly, particularly children from economically weaker families who do not have the luxury of space to isolate COVID-positive members. Sunita Gore, 35, works as a cook for two families in an apartment building in Thane. She lives with her construction supervisor husband Sakharam, 40, and three children in a one-room tenement with an attached kitchen. After she tested positive for COVID-19, she applied to the municipal corporation for a room to isolate in, as there was no chance of self-isolating in their tiny home. Fortunately for the Gores, they did not end up needing the municipality room, as Sunita could move into a neighbour's home that was vacant at the time. She also had a mild case of COVID-19.

While Sunita was in isolation, it fell on 17-year-old Neha to cook for her father and younger siblings, as well as for her mother. "I had never really cooked before and I would get tired," Neha said. She would make food as best as she could with instructions from her mother on the phone. "The food was edible," Neha told IndiaSpend.

Some days after their mother tested positive, Neha and her brother Ayush (16) both had slight headaches. Then, Neha vomited in the middle of the night. "We weren't sure if it was because she had COVID-19 or because of the food, as she was not used to cooking," said Sunita. The Gore family got retested and by this time Sunita tested negative, but Ayush, Neha and their father all tested positive. Only the youngest child Chetna (nine) was negative, and so she stayed with Sunita, said Neha.

Then, Sakharam's condition worsened and the Gores could only wait and watch while his friends and Sunita's employers began a frantic search for a hospital bed for him, he told IndiaSpend. By this time, his oxygen levels had fallen below 94. "I was a little scared about what would happen," but once Sakharam was admitted to the hospital, he started recovering, said Neha.

It was Neha and Ayush's turn to isolate in the neighbour's room. They stayed there alone for about eight days while their father was in hospital. We would get tired of being cooped up in the room, and would fight a lot, but at least it was two of us together, said Neha. They were anxious about their father, and would talk to him on the phone every day. He would reassure them that he was getting better. It was only later that they learnt of an oxygen shortage that lasted a couple of days at the hospital--her father did not tell them such details, said Neha. "He would just say he is feeling fine," she said.

"We were fortunate that we could rely on support from our neighbours and employers. Our extended family living nearby would shop for us and send food whenever they could. We are all fine now but I have still not recovered completely," said Sakharam.

Doman Raut, 42, lives with his wife and two children in a one-room house in Indore, where he works as a cook. He was hospitalised after testing positive for COVID-19, but was discharged six days later. Worried that his family could get infected next, Doman's employers asked his wife and two children to move into their house so that Doman could stay in isolation until he tested negative. The separation made his children anxious about his health. "Hemant [his 10-year-old son] would call me crying in the middle of the night, wanting to do a WhatsApp video call because he was worried about me," Doman told IndiaSpend.

Overwhelmed children

COVID-19's impact on children is more than just that of the virus—they feel lonely, isolated and fearful, doctors and families told us.

"On the first day I was scared and then mummy talked me through it," said Nandika, who was the first one to be detected with COVID-19 in the family. "In a few hours, I was feeling fine, but I wasn't allowed to go outside," she said. Nandika said she was not worried about herself, but was worried for her brother and father. "Are they going to be fine?" she would think. Her father had developed pneumonia and had difficulty breathing, along with a high fever and loose motions.

Shrihaan, her brother, would also worry about his father. "What will happen now," he would think. Shrihaan was isolated with his father as both of them had symptoms more severe than Nandika or Puneeta. "Small things I could do, I did. Whatever I could do. Daddy could not breathe well and had to do breathing exercises. I would help as much as I could," said Shrihaan.

"I was confused and bewildered at first, about how I could have got COVID-19 when all of us had been so careful," said Pranava Kochhar, 13, a resident of Thane, Maharashtra. "First my mother got infected, then my elder sister and I. I was irritated at having to be stuck indoors again, as I had a fever and had to be in bed for about a week. But when my mother developed pneumonia and had to be hospitalised, I was so worried about her, and also about what would happen to us. It fell on my father to take care of everything, mom, us and the house, and he did," he said. "One comfort when my mom was in hospital was that my grandmother and aunt were nearby and could send us delicious food while we were recovering. So did our neighbours. Eventually we all recovered. Still, I only felt okay when my mother returned from the hospital. I hugged her for a full 10 minutes when she came back home," he told IndiaSpend.

For both Nandika and Shrihaan, their friends helped them pass the time in isolation and encouraged them not to worry. They would also play games on the mobile phone and watch TV. Shrihaan, an introvert, did not mind being cooped up indoors, but Nandika, a social butterfly as her mother calls her, found it difficult to be isolated from her friends.

The greatest fear that children have is staying alone in a room without a relative, especially if they are admitted to the hospital. "It is very important for a child to have someone around," so we have very good staff to counsel them and try to relate with them as family would, said Bodhanwala.

Reopening schools

Some children are more at risk from other impacts of the pandemic. "The harmful effects of this pandemic will not be distributed equally. They are expected to be most damaging for children in the poorest countries, and in the poorest neighbourhoods, and for those in already disadvantaged or vulnerable situations," the United Nations Children's Fund (UNICEF) said in the early months of the pandemic. With schools shut, the pandemic will have an impact on learning and on mental and physical growth, said UNICEF.

Doman's two children, Hemant, 10, and Riti, 6, attend a low-cost private school in Indore. "The children are going to forget everything they have been taught. They do not really understand much through online classes or lessons sent over WhatsApp. We are really worried about what is going to happen next year. The school has not informed us yet," said Doman. Pranava too is anxious about how the classes and exams he missed while down with COVID-19 will affect his academic record.

Should schools then be reopened? "At this point, not opening is a better decision, which needs to be constantly re-evaluated as time passes," said Khosla, even as she agrees that not reopening schools means increased mental stress plus the dangers of more sedentary living, such as obesity, for children.

Bodhanwala warns of a third wave in August 2021, adding that schools can be reopened once COVID-19 vaccines are available for children. The government should start planning strategically for reopening schools, said Bodhanwala. "Don't think the second wave is the end of COVID-19. It could go on to the third wave, it could prolong. People should take all the precautions and not hesitate to take the vaccinations as at least the symptoms are reduced," Bodhanwala advised.

Even if schools are reopened, parents like Puneeta are reluctant to send their children. "I don't think I will send them to school until the vaccines are up and about," she told us.

Now that his family has endured COVID-19, Shrihaan said he is not worried about the disease and believes it is manageable. The Tandon siblings still have minor symptoms once in a while, such as a headache or tiredness, but Puneeta isn't sure if they are related to COVID-19 or just fatigue. Shrihaan tells of a friend who was terrified after being diagnosed. "I told him everything will be fine. Just give it a week. All your symptoms will almost go. Just be patient."

(Khaitan is a writer/editor with IndiaSpend.)