Coronavirus (COVID-19): Advisory Sub-Group on Education and Children’s Issues - evidence on children, schools, early learning and childcare settings and transmission- summary report

Health and wider consequences of COVID-19 for children and young people

COVID-19 related health harms

Compared to adults, children and young people under the age of 18 are at much lower risk of severe COVID-related health outcomes such as hospitalisation and requirement for intensive care, or death. Children are susceptible to and can transmit SARs-COV-2 but are less likely to acquire the virus.   Once infected, they are more likely to experience mild or asymptomatic infection.  Severe illness, hospitalisation and mortality are thankfully rare .  

Although the Delta variant of concern (VOC) has higher transmissibility and a higher risk of hospitalisation than the Alpha VOC, there is no current evidence suggesting that it impacts children and young people disproportionately.  While the Delta VOC is more transmissible across all the age groups, children and young people will make up a greater proportion of cases in countries like Scotland where there is very high vaccination coverage among adults.

In Scotland, between March 2020 and 5 July 2021, there was one death due to COVID-19 in the <1 year age group and two deaths in the 1–14-year age group. As the vaccination programme rolls out in the older age groups in the population, it is expected that children and younger people will form a greater proportion of new COVID-19 cases, but that the health harm associated with these cases will remain much lower than was seen among unvaccinated adults.

Since the start of the pandemic in Scotland, there have been 329 admissions to hospital of children aged 0-9 years, and 259 admissions of children and young people aged 10-19 years, with a recent COVID-19 diagnosis (which is up to 0.05% of the population of the 0-19 age group). The proportion of children and young people who have tested positive for COVID-19 who are admitted to hospital within 14 days has remained low and stable, at between 0.5% and 2% in the period December 2020 to June 2021.   

Across the UK and the Republic of Ireland, COVID-19 paediatric intensive care admissions have been monitored by Paediatric Intensive Care Audit Network (PICANet) and in the most recent report to 11 June 2021, there had been a total of 291 children under 18 years admitted to intensive care with a positive COVID test across all areas. It should also be noted that the need for individuals to be included in the Highest Clinical Risk group is reviewed constantly, including for children and young people, and this will be updated as new evidence emerges.

There is evidence that a small number of children have required intensive care admission having developed a Paediatric multisystem inflammatory (PIMS or PIMS-T) that is associated with COVID-19, which appears around four to six weeks after initial infection. 15, 16 Distinct from PIMS, recent research has highlighted that children and young people can experience persistent symptoms associated with long-COVID  including fatigue, followed by dyspnoea and difficulties concentrating . However, the evidence base is incomplete  and rapidly developing. The precise burden of COVID-19 and enduring symptoms on children is unknown  . 

Long-COVID

If infected with COVID-19, children and young people are more likely than adults to experience mild or asymptomatic infection.  Severe illness, hospitalisation and mortality are rare.   Over the time of the pandemic, however, concerns have grown about the longer-term effects of infection, known as ‘Long-COVID’.  The REACT-2 studies  of people in the community in England found that around a fifth of those surveyed reported having had a COVID-19 symptom previously, with over a third of these reporting at least one symptom lasting 12 weeks or more. The prevalence of persistent symptoms increased with age, with a 3.5 percentage point increase in likelihood in each decade of life. The prevalence of long-COVID was higher among women, people who are overweight or obese, who smoke, live in deprived areas, or had been admitted to hospital. These studies did not look at long-COVID in children.

Children and young people can experience symptoms associated with long-COVID  including fatigue, followed by dyspnoea and difficulties concentrating . However, the evidence base is incomplete  and rapidly developing. The JCVI statement on COVID-19 vaccination of children and young people aged 12-17 years  confirms the low risk of prolonged symptoms in this age group, stating:

“Concerns have been raised regarding post-acute COVID-19 syndrome (long COVID) in children. Emerging large-scale epidemiological studies indicate that this risk is very low in children, especially in comparison with adults, and similar to the sequelae of other respiratory viral infections in children.”

The sub-group will continue to review the evidence on acute and prolonged health effects of COVID-19, and will update advice if required in light of new findings.

Wider health and wellbeing

There is consistent international review-level and UK evidence that the COVID-19 pandemic and the related public health control measures have adversely affected the mental health and wellbeing of children and young people with a range of negative emotional, behavioural and wellbeing outcomes reported. Adolescents and girls were reported to be more affected than children and boys, respectively.   

Levels of stress, depression and anxiety among caregivers of young children (0-8 years) has been found to be associated with reduced responsive caregiving.  Financial insecurity was consistently identified as an important source of stress.  However, a number of studies found that the restrictions during lockdown were linked with improved family relationships    improved mental health and wellbeing scores among adolescents with pre-existing mental health issues and a decrease in challenging or disruptive behaviours reported by parents of children with attention deficit hyperactivity disorder. 

There is inconsistent evidence about the impact on children and young peoples’ physical activity and dietary habits during COVID-19 related school closures.  Several studies report that levels of physical activity decreased  and sedentary behaviours increased, while others report an increase in physical activity levels. In a Welsh study, the number of takeaways consumed per week had significantly decreased during the school closures in the first national lockdown, while sugary snack consumption had increased.  

International review-level evidence about the effect of COVID-19 related school closures on educational outcomes is mixed, with some studies reporting a negative effect and others reporting a positive effect.  Younger children and those from low-income households have been found to be more adversely affected.  In an English study, the estimated learning loss of learning in reading after the first COVID-19 related school closures was 1.8 months for primary school-aged children and 1.7 months for secondary school pupils. The learning losses in mathematics were greater. On average, pupils from disadvantaged backgrounds  had experienced greater learning losses than their more affluent peers.  

There is international review-level evidence that the number of referrals to child protective services for potential abuse, neglect and maltreatment of children and young people was reduced during the COVID-19 related restrictions in the first wave of the pandemic. The proportion from schools fell by up to half, highlighting the role of schools and early learning and childcare settings in identifying potential cases. There were rises in child abuse-related injuries in babies and toddlers also reported. 

There is consistent international review-level and Scottish evidence that paediatric emergency department attendance fell markedly in national lockdowns during the first wave of the pandemic in comparison to previous years. The proportion of attendees who required emergency hospital admission increased.  

While many studies do not consider how children and young people’s social circumstances may modify outcomes , there is emerging evidence that population sub-groups of children and young people, such as those with a parent in the justice system, those living in low-income households and those with special educational needs or neurodevelopmental difficulties  have been disproportionally affected by the pandemic and the related restrictions.

Many of the studies that examine the impact of the pandemic and related restrictions on children and young people’s health and wellbeing use cross-sectional designs with recruitment processes that introduce a source of bias. There tends to be reliance on self-report or parent-report measures. Often, it is not possible to tell how representative the participants are of a general population.