November 1, 2021 Vol. 10: A Nuanced Perspective – Whether Parents Should Vaccinate 5-11 Year Olds

On October 26th an independent advisory panel to the FDA, comprised of the country’s top scientists, epidemiologists, immunologists and physicians, voted 17 to zero to recommend a smaller dose of the Pfizer-BioNTech Covid-19 vaccine for children ages 5 to 11. The FDA and CDC will undoubtedly accept and ratify the panel’s advice within days and the Pfizer-BioNTech vaccine (aka Comirnaty) will soon be available to all but the youngest people in the United States. 

This is a watershed moment. Even in our boutique practice, mostly since the Delta variant became dominant since July 2021, more than a handful of parents have transmitted COVID to their children and we have now begun to see peer to peer school transmissions as well as children passing the virus to adults. Thus far, of those children who contracted COVID, one has been enduring long haul symptoms for three months and counting. It hasn’t been easy for these families, and I am grateful there will soon be a vaccine option for kids ages 5-11. 

At the same time, the decision whether to vaccinate your 5-11 year olds is a nuanced one. It’s important to consider your family’s medical history, your personal and family circumstances, the level of community spread, as well as your risk tolerance. Below, I discuss a number of factors to weigh, such as kids’ mental health challenges, the risk of long COVID, and that we now understand COVID19 is far more insidious than a respiratory disease, in deciding whether to vaccinate your younger children. And while, generally, my recommendation is to vaccinate 5-11 year olds, I acknowledge that there are individual  circumstances where my advice would be different. Please understand that my objective here is to provide up-to-date, fair, balanced and dispassionate information for those who seek it.

Kids Get COVID
Contrary to suggestions early in the pandemic, kids definitely get and spread COVID and the highly transmissible Delta variant has been a real game changer. In the United States, more than 6 million children have been infected with SARS-CoV-2 or COVID19. Within the 5-11 age group, “more than 1.9 million…have been infected by COVID19 during the pandemic, and during Delta, there was a sharp increase in cases; 5-11 year olds represented 10.6% of cases in the week of Oct 10 (they make up 8.7% of the population).” Additionally, a new (but small) study from Australia suggests that, unlike adults, children who contract a mild case of COVID may not develop robust antibodies to the virus.

This finding, assuming other scientists validate it, could mean that unvaxed children will be particularly susceptible to re-infection, which would result in greater opportunities for them to spread COVID and infect others, including infant siblings, grandparents, immunocompromised classmates, teachers, and so on. After all, we already know that kids are significant vectors for infection in their families and have driven Britain’s longest running COVID surge.

COVID Can Impact Every Organ System and Some Kids Are Hospitalized for COVID
While most COVID infections have been mild for a majority of kids, more than 23,500 kids have been hospitalized for COVID. As of August 2021, 5-11 year-olds had the highest rate of hospitalization since the beginning of the pandemic. And, of the more than 8,300 COVID hospitalizations of 5-11 year-olds, over 30% had no underlying health condition. Once hospitalized, 1/3 of these children ended up in the ICU. 

Long COVID Impacts Kids
Another risk of  contracting COVID is “long COVID,” and it affects children as well as adults. Long COVID is characterized by a variety of symptoms, including headaches, difficulty breathing, brain fog, joint or muscle pain, loss of smell and more. These symptoms may wax and wane in the weeks or months following an infection. It doesn’t matter if the infection was mild or severe – anyone who contracts COVID can end up with long COVID. 

Some estimates are as high as 15% of children who are infected developing long COVID. In other words, as many as 930,000 of the nearly 6.2 million kids (so far) who tested positive for COVID could end up with long COVID. Even if the likelihood of “long haul” in kids is “only” half of the aforementioned estimate, by the time a child has had COVID two or three times (because they lack robust antibodies or because they haven’t been vaccinated and thus are more than twice as likely to be reinfected compared to the vaccinated), the compound risk for long COVID should be seriously considered by parents. 

Frankly, as a pediatrician, my view is that in most cases the chance for children to contract long COVID due to not being vaccinated presents an unacceptably high risk simply because we don’t yet know how this will play out in the long term (e.g., 10, 20 or 30 years from now). Kids have their entire lives ahead of them, and long COVID could negatively impact their development and quality of life in a meaningful and ongoing ways. Some kids with long COVID are battling cognitive difficulties, others are dealing with anxiety and depression, and still others are not able climb a flight of stairs without severe shortness of breath. Long COVID is a scary big deal. 

Though vaccines aren’t perfect at preventing infection and may not confer 100% protection against long haul, the more of us and our kids that are vaccinated, the less likely they (and we) are to be infected in the first place. Further, significant studies convincingly prove that vaccinating children significantly reduces the risk of hospitalization and death. Yes, some have argued because there isn’t enough safety information available yet, for this reason vaccinating children should be avoided. Tell this to a parent whose unvaxed child has died or is maimed after being in the ICU due to COVID19.

Risk of Death
According to the CDC, over 600 children ages 18 and under have died from COVID. Within that group, “[t]here have been ninety-four 5-11 year olds that have died from COVID19 in the United States. For context, this places COVID19 as the 8th leading cause of death for this age group. More recently (during Delta), COVID19 jumped to the 6th leading cause of death in this age group.”

Kids’ Mental Health Matters – COVID Has Taken a Huge Toll
As you no doubt witnessed during remote schooling, COVID has been hard on kids. In fact, your child may still be recovering social and academic skills that took a hit when we were all sheltering in place. As Dr. Lee Savio Beers, President of the American Academy of Pediatrics recently wrote, 

“The pandemic has also deepened an existing mental health crisis among young people. Over 140,000 American children have lost a caregiver to Covid-19. Pediatricians across the United States have seen a rise in young patients with eating disorders, depression and suicidal thoughts. That’s why the American Academy of Pediatrics and other children’s groups recently declared a national state of emergency for children’s mental health. Educational gaps are also widening, with reports suggesting American students are behind in math and reading. These consequences are all magnified for low-income families and families of color.“
 As an integrative pediatrician, I am as concerned about a child’s mental health as I am about their physical health. It’s urgent that we return to a life that includes a wide variety of social interactions and school attendance without the constant fear of contracting and spreading COVID. Additionally, we need to avoid another long term interruption of our kids’ educational and social lives. We cannot accomplish these things without vaccinating a large percentage of the roughly 28 million 5-11 year-olds in the US because of their roles in spreading the virus and that COVID19 is rapidly turning into a pandemic of the unvaxed. In other words, as more adults and teens are vaccinated, COVID will continue to seek out and find the unimmunized including children. 
Personalized Counseling
Based on the available science and data, I am recommending COVID vaccination for most 5-11 year-olds with certain important exceptions. I believe that vaccination (and the other proven steps like masking in indoor settings) is the way out of this pandemic, and this path must include immunizing children and teens, who comprise more than 20% of the population. 

At the same time, I recognize that some of you may be feeling hesitant about vaccinating your young children. For example, if your son or daughter has tested positive for COVID at some point in the last 6-9 months, you may not be sure immunizing them makes sense or is safe. If that’s the case, let’s talk so we can address your questions and worries. In general, however, in that scenario, I’d recommend a single dose for now (for those kids who have had documented COVID in the last 9-months) to achieve a sort of “hybrid immunity.” This single dose will act as a booster and your child will likely receive the benefits of the vaccine in a single dose. Based on public comments by health officials in California and Governor Newsom, it is probable that by the summer of 2022 California will mandate vaccinating children as a condition to attending public or private schools. The hybrid approach buys extra time before committing to a 2-shot regimen.

Vaccine Availability 
It’s been all over the news that pediatricians are gearing up for putting shots in arms (and legs). Since the Pfizer vaccine remains government sponsored and paid for, highly regulated and tracked, and the data are in part being collected through insurers and MediCal, GetzWell has not been a high priority for distribution. As a small boutique practice the government has not made it easy for us, though we expect to have vaccines available in 2022. This, of course, doesn’t mean your child can’t receive a vaccine if you want one. Most of the large national pharmacies (like Walgreens and CVS) in our communities and many schools will be offering them as soon as the CDC gives its approval, which is anticipated next week.

In closing, again, I invite you to contact us if you are questioning vaccinating your 5-11 year old and would like to discuss your concerns. We will not only help you assess any personal risk factors, but we can also help figure out if what you have read, heard or thought is based on the science and data or on unsound, or even false, information. Be safe!